Susan Blank, M.D. is the Chair of the American Academy of Pediatrics Task Force on Circumcision
January 18, 2010
Susan Blank, M.D.
New York City Department of Health and Mental Hygiene
125 Worth St. Box 73
New York, NY 10013
Dear Dr. Blank:
Our organization has a strong interest in the work of the American Academy of Pediatrics Task Force on Circumcision. As you know, the AAP Committee on Bioethics issued a relevant policy statement in 1995, “Informed Consent, Parental Permission, and Assent in Pediatric Practice,” which was reaffirmed in 2007. There appear to be conflicts between the Bioethics Policy, the 1999 Circumcision Policy, and related documents that you may want to resolve as you work on the new circumcision policy, and I request your assistance in clarifying some ethical concerns. Given the importance of the circumcision issue to many people, clarification of these points would help us to accurately educate others. I understand that your responses do not necessarily represent those of the Task Force.
According to the American Medical Association Principles of Medical Ethics, a physician shall provide competent medical care with respect for human dignity and the rights of patients and “regard responsibility to the patient as paramount.” The Bioethics Policy says, “Pediatric health care providers . . . have legal and ethical duties to their child patients to render competent medical care based on what the patient needs, not what someone else expresses . . . [T]he pediatrician’s responsibilities to his or her patient exist independent of parental desires or proxy consent” (p. 315). The 1999 Circumcision Policy states that parents “should” make the decision about non-therapeutic circumcision, implying that doctors should comply with parental desires.
Question 1: Is a physician’s compliance with a parental request for non-therapeutic circumcision consistent with rendering “competent medical care based on what the patient needs?” Please explain.
Citing the Bioethics Policy, the 1999 Circumcision Policy states that parents must make choices about health care for infants and young children because infants and young children are not capable of making their own decisions. However, these decisions are related to diagnosis and treatment for an ailment. Non-therapeutic circumcision is surgery performed on a child with no ailment, and circumcision is not treatment.
Question 2: Should parents make health care decisions for infants and young children that do not relate to an ailment or treatment? Please explain.
According to the 1999 Circumcision Policy, pain medication is “safe and effective in reducing the procedural pain associated with circumcision” (emphasis added, p. 689). The AAP policy on “Prevention and Management of Pain in the Neonate” recommends “minimizing the number of painful disruptions in care as much as possible.”
Question 3: Ethically, can any pain be justified in a surgical procedure that the 1999 Circumcision Policy acknowledges is not essential to a child’s well-being? Please explain.
The Bioethics Policy says, “A patient’s reluctance or refusal to assent should also carry considerable weight when the proposed intervention is not essential to his or her welfare and/or can be deferred without substantial risk . . . Coercion in diagnosis or treatment is a last resort” (p. 316). In surveys and clinical practice, some circumcised men have expressed anger that they were forced to be circumcised: “No one had the right to cut my foreskin off!” “I feel cheated at having been robbed of what is my natural birthright.”
Question 4: Since infants are forcefully restrained and clearly protest being circumcised, and circumcision is not essential to a child’s well-being and can be deferred without substantial risk, is circumcision of an infant done by “coercion?” Please explain.
Non-therapeutic circumcision is viewed by many ethicists as unethical.
Question 5: Is circumcision an exception to accepted medical ethical principles and practice? Please explain. If yes, please comment on the justification for making an exception and how an exception may affect the credibility of and adherence to these principles.
I also want to mention the AAP Female Genital Mutilation (FGM) Policy Statement. In that statement the AAP “recommends that its members decline to perform any medically unnecessary procedure that alters the genitalia of female infants, girls, and adolescents” (p. 155).
The parallels between cutting female genitals and cutting male genitals are notable. The FGM statement reports, “Some women have no recollection of the event, particularly if it was performed in infancy, while others deny that the procedure has had any negative effect on their health or sexual life” (p. 154). Similar claims have been made by circumcised men and can be explained by psychological theory and principles. The FGM Policy also states,
Parents are often unaware of the harmful physical consequences of the custom, because the complications of FGM are attributed to other causes and rarely discussed outside of the family. Furthermore, parents may feel obligated to request the procedure because they believe their religion requires female genital alteration (p. 155).
These statements may also be said for cutting male genitals.
Noting the position of the AAP against FGM, a letter to the editor of Pediatrics called on the Circumcision Task Force to “afford the same protection to our male patients . . . . and refuse to perform unnecessary mutilating procedures on our patients simply because of their parents’ desires.”
Male circumcision is not the only genital surgery that has been defended with claims of potential benefits. As recently as 1973, female circumcision was suggested in a medical journal as a treatment for frigidity. Another author suggested female circumcision to treat a non-retractable clitoral hood. The surgical procedure was covered by Blue Shield until 1977. Some observers have suggested that if there were as much research seeking potential medical benefits for FGM as there is for male circumcision, more potential medical benefits for FGM would be reported.
Question 6: Would you approve of female genital mutilation at the request of parents in its most minor form (excision of the clitoral prepuce, similar to excision of the penile prepuce) if such a procedure were reported to have “potential medical benefits?” Please explain.
I would appreciate a prompt reply letting me know that you received this letter and providing an estimate of when you can respond in full. For your convenience, please use my email at email@example.com.
Thank you very much for your attention to this request, and I look forward to your response.
Very truly yours,
Ronald Goldman, Ph.D.
Note: In 2013 Susan Blank, M.D. was invited by a national newspaper to participate in a written debate on circumcision with Ronald Goldman, Ph.D. She refused.
No response was received.
A similar letter was sent to Kathryn Moseley, M.D. on 10/7/02. She served on the AAP Committee on Bioethics, which issued a 1995 statement “Informed Consent, Parental Permission, and Assent in Pediatric Practice.” This Committee approved the 1999 Circumcision Policy Statement which conflicts with the 1995 Bioethics statement, as stated above. She did not respond.
Similar messages were sent to other members of the AAP Task Force including (all MDs) Ellen Buerk, Douglas Diekema, Steven Wagner, Waldemar Carlo, Michael Brady, Lynne Maxwell, Andrew Freedman, Sabrina Crago, Peter Kilmarx, and Lesley Atwood. Others at the AAP who received copies were Errol Alden, Jay Berkelhamer, Dan Walter, Renee Jenkins, Roger Suchyta, and David Tayloe. Those at the Centers for Disease Control working on circumcision policy also were included.