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Science Requires Ethics, Revisited

Jake Waskett responded to my critique of his entry about Intact America's letter. I find it lacking.

... It's a shame that he mischaracterises me as a "pro-circumcision advocate", though (I'm pro-parental choice, not pro-circumcision).

I do not accept that I've mischaracterized his position as a pro-circumcision advocate. However, I'll clarify to be as specific as possible. He believes the potential benefits of infant male circumcision outweigh the risks and negatives, a subjective conclusion based on his preferences. Given that he uses his conclusion to encourage parents to circumcise their sons, the difference he states is immaterial.

Next:

... has attempted a deconstruction of the letter, labeling it "propaganda".

"Labelling" seems a curious choice of word, implying that the choice of term is dubious. Propaganda is defined as "The systematic propagation of a doctrine or cause or of information reflecting the views and interests of those advocating such a doctrine or cause." Thus, it seems a perfectly appropriate choice of term for an advertisement created by an anti-circumcision organisation for the explicit purpose of promoting their cause to the AAP.

This is a matter of semantics versus intention. Definitionally, propaganda is an acceptable choice. It is also impossible to ignore the cultural implication of the use of the word. We do not think marketing when we hear it. Rather, we hear lies. That was the intent I perceived, which informed my response.

Still, it's a minor point in the realm of this topic. Obsessing on it would be a diversion, so I retract the point.

Next, when I wrote that I agreed with the opening paragraph of Intact America's letter, I stated that I'm not a fan of appeals to authority. Specifically:

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.

Jake writes that this is "utterly incomprehensible." I'm not sure how, so I'm not sure how to clarify. If an authority cited directly (e.g. AAP) or indirectly (e.g. CDC) changes its position in a way that then conflicts with the original appeal, the appeal to authority may weaken the case for the target audience. It's an ineffective strategy.

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.

Tony is, of course, free to subscribe to whatever system of ethics he so chooses. However, to my mind he is setting an extraordinary requirement: that an intervention should not merely be medically beneficial, but must actually be necessary. If applied consistently, such a standard would mean, for example, that vaccinations are unacceptable, since they are rarely necessary.

His assessment is close, but too neat for this complicated comparison. That is the requirement I set for proxy consent to surgery. The scenario for vaccinations differs. As I wrote before, the difference rests on how the problems the interventions are meant to prevent occur. 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. Later in his reply, he writes about this:

This is a nonsensical argument: it is absurd to analyse the issue as though children never grow up. Peter Pan is fiction. Children grow up to become adults, and yes, that includes having sex.

Of course, to which I reply as a start: condoms. Condoms are among the many possibilities short of circumcision as an infant available to adult males, including circumcision as an adult, to reduce the risk of HIV transmission.

Ultimately the comparison to vaccines must rest on diseases like HIV rather than the other potential benefits used to justify circumcision. They roughly share some of the same characteristics. The comparison fails because, as I wrote, the way in which the diseases spread differ. For most vaccines, it is the most effective and least invasive way to stop the spread of the targeted disease. With comparable diseases, circumcision is neither the most effective or the least invasive method available.

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.

Tony's words are somewhat misleading here. There haven't been any controlled trials of voluntary circumcision in MSM yet. The American studies to date have mostly compared previously (and probably neonatally) circumcised men with uncircumcised men. Some studies have shown a statistically significant reduction, but others have not.

Fair enough on precision. However, an implicit point in my argument here stands unaltered. Assuming voluntary adult circumcision is shown to reduce the risk of all forms of HIV transmission through sex, parents can't know that their sons will be irresponsible and "need" this intervention. It's a speculation that does not need to be made for a child. He can choose it later.

Responding to my declaration that surgical risks be weighed against objective (lack of) need rather than potential benefits, Jake replies:

As Tony correctly observes, the situation we're discussing is not one in which there is an immediately pressing need for therapeutic intervention, hence the "most effective and least invasive" criteria for choosing that intervention do not apply. Instead, the situation involves a healthy child, much as with vaccinations. And as with vaccinations, we weigh the risks (adverse reaction) against the future benefits (reduction of risk of disease). Tony is of course free to apply his own ethical standard, but he should not be surprised that others choose not to follow him.

There is no need, so "most effective/least invasive" doesn't apply? Jake is begging the question he wants to answer rather than addressing objective facts. He's saying that the standard for surgical intervention on a child should be stricter when the child is sick than when he is healthy. Parents can be more speculative and exploratory with surgery for their healthy (male) children? That's ridiculous. Without objective need for an intervention, proxy consent for surgery can't be valid. With objective need, it can be valid because the child needs some form of decision made and he is incompetent to make that decision.

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.

Unfortunately, Tony hasn't identified any of these "surgeries we recognize as offensive" that are valid when benefits and risks are properly weighed. I would be interested to learn of any that he - or anyone else - can think of.

I am not citing any particular science or surgeries because that was not my point. I am attacking a way of thinking, particularly about the ethics of circumcising healthy children, but it applies more generally. Jake is a utilitarian. I am not, precisely because of the way it permits his mixing of subjective criteria into a universal recommendation. I recognize that each person is an individual with different preferences and desires. Prophylactic (and ritual) circumcision violates that child's rights.

But to his retort, if a study were to find potential health benefits for genital cutting in a study of adult female volunteers, would that be acceptable to apply to healthy female minors? I've had this discussion with Jake previously, so I know he'd have no problem with it if parents subjectively valued the benefits more than the risks. He is wrong. Society would be (correctly) outraged at the suggestion of violating the child's rights in favor of her parents' "rights". Our anti-FGM laws would not be overturned. Those results would never be applied, regardless of the science.

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 Jake'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.

This paragraph makes no sense.

That paragraph is clear. We apply different standards to boys and girls. A female minor's risk of UTI is higher than that of a male minor's, yet we do not vigorously seek proof that genital cutting is the answer, nor, as I said above, would we apply it to infant girl if we could find such results. Now replace UTI with cancer. Ethically, we'd have the same approach to girls. Their genitals would be off-limits.

[Quotation of my words omitted]

If Tony had been paying attention, he would have noticed that I actually identified the three reasons why IA claimed that circumcision was unethical, and addressed each in turn.

As I've explained, Jake's version of ethics is flawed because he values only his own opinion as a viable conclusion on the subjective topic. Proxy consent requires objectivity first. A passive-aggressive insult directed at my reading comprehension does not prove that I was wrong.

As a reminder, here is what IA claim: "Doctors have a responsibility to tell parents the truth: circumcision does not prevent disease. Most European nations, with circumcision rates near zero, have lower HIV/AIDS rates than the United States."

As I read that, the second sentence seems to be presented as evidence for the first. If that is so, IA appear to be saying that the most definitive evidence can be found in between-country comparisons.

I read it a differently, based on the context of how the letter is organized. I will not defend the statement Jake objects to because I believe Intact America's statement is poorly written. I read it as saying a) studies have found that (voluntary, adult) circumcision has been shown to reduce the risk of (female-to-male) HIV transmission and b) other similar countries that do not circumcise have lower HIV rates, therefore c) infant circumcision is not the answer. I made that point in my response. Doing so in the way that he did, it's clear we're using different interpretations. I do not think Jake is wrong to call out Intact America's wording.

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.

If Tony is confident in his assertions, perhaps he will volunteer to have heterosexual intercourse with an HIV+ woman. Probably not, I suspect, because of course that's a risk anywhere. The main difference, of course, is that the probability of exposure changes dramatically. Put bluntly, if you sleep with a person then your risk of acquiring HIV depends on the probability that they are HIV+.

Jake establishes a straw man here. I made a statement of fact about HIV transmission in the United States. His rebuttal is that I should be willing to have sex with an HIV+ woman because I state that voluntary, adult circumcision applied to infant males is not what we need. Presumably he means without a condom. Where have I said that unsafe sex - of any kind, with or without a foreskin - is wise? Jake's scenario is a stupid diversion.

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.

It is not meaningful to compare female genital cutting to circumcision. Female genital cutting is a net harm, with no known medical benefits, immediate risks, and a considerable chance of permanent harm. Society passes laws to protect the vulnerable from harm, and so it makes sense to protect children from female genital cutting. But - applying the same principle - it doesn't make sense to legislate against circumcision, because there is no net harm. Most reasonable people, weighing the risks and benefits, come to the conclusion that it is neutral or beneficial.

It is meaningful to compare female genital cutting to male genital cutting because, ethically, they involve the same issue. Unnecessary surgery on a non-consenting individual is wrong. America's anti-FGM law makes no exemption for potential benefits or parental opinion. The former is, as Jake points out, not shown by studies. The latter is all that informs infant male circumcision, since an evaluation of potential benefits is opinion absent any objective indication for the child's healthy genitals. There is an obvious double standard. Girls may not have their healthy genitals cut for any reason. Boys may have their healthy genitals cut for any reason. That's the valid comparison.

To Jake's claim of "no net harm" from male circumcision, I'll repeat that it is a subjective evaluation. It is his opinion. I weigh the objective harms - scar, lost nerves, excised frenulum, asymmetrical suturing, altered functionality - from my "normal" circumcision differently than he weighs them from his (self-chosen) circumcision, but he is not me. As he was correct in deciding on circumcision for himself, I am correct in evaluating it differently for my body. Not Jake, not my parents, not "most reasonable people", not whoever else he wishes to cite who approves of circumcision. That gets lost in his utilitarian disregard for ethics on a topic without a valid objective conclusion for his position.

Comments

There's a response here, Tony.

Jake asserts that the sexual harm of (routine neontal) circumcision is zero, but he is unable to prove that assertion, and an important part of his argument comes crashing down without it. His claim of neutrality is an artifice of the way he calculates harm as some mathematical sum. Even if he could assign numerical value to harm, the sexual value of circumcision at birth must be zero or negative (if we mean that a botched circumcision receives a negative value.) The rate of complications posted by circumcisers is small, but the product with millions of circumcisions produces a significant population of men whose penises were unequivocally harmed. For Jake to be correct about zero net harm, there would have to be some crossover point when the speculative sexual benefits of circumcision outweigh the proven harms. Of course this benefit is impossible to prove. The best that "science" can prove is that circumcised men can feel fine wires pressed onto their penises and elbow as well as intact men - the synopsis of the much ballyhooed study by Payne et al.

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