Advocacy: Rhetoric or Practice

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Advocacy: Rhetoric or Practice

Iva Phillips, R.N.
Nursing BC, p. 37-38, September 1994

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The topic of routine male infant circumcision has been a controversial issue among many nurses. At the 1994 RNABC annual meeting, delegates voted not to allow resolution number 55 (routine newborn male circumcision) to come to the floor to be discussed. It is considered controversial to many nurses and other health care providers because circumcision is:

a medical procedure;
a religious/cultural issue;
an issue of informed consent, which is a physician's role;
too controversial for nurses to discuss.

All these are indefensible. Circumcision definitely is a nursing issue.

Medical Procedure

The Canadian Paediatric Society, in Treatment Decisions for Infants and Children, declared: "the primary concern of physicians caring for children must be the best interests of the individual child." The society defined best interests as "the balance of potential benefit over potential harm or distress resulting from the pursuit of a given line of treatment."

Medical indications for performing circumcisions are: phimosis, peripheral adhesions, ballooning of foreskin, and balanitis. Between one and two percent of boy require circumcision for these medical reasons.¹

Medicine based on parental demands (is) "vending machine medicine
(which) is inconsistent with good medical practice.

The British Columbia Medical Services Plan pays for medically required circumcisions. Only 37 such circumcisions were performed in 1992 of the 23,509 males born in B.C. The current provincial rate of circumcision is 40 percent. Therefore approximately 10,000 circumcisions were performed for non-medical reasons. They were non-therapeutic and were not classified as a medical procedure. These circumcisions were performed by the physician at the request of the parent(s). However, physicians can ethically and legally refuse to treat a child despite parental objections when that treatment is not in the child's best interests. Lawrence and Robert Nelson state: "it is inconsistent with a child's best interests to impose a burden disproportionate to the benefit achieved or to demonstrate disrespect for a child's dignity and worth as a person."²

The Nelsons refer to the practice of medicine based on parental demands as "vending machine medicine (which) is inconsistent with good medical practice." Circumcisions performed on parental demand are non-therapeutic and therefore do not qualify as a valid medical procedure.

Religion/Culture

Circumcisions done for the personal preference (culture) or religion of the parent(s)
deny the infant the basic right to respect and autonomy

Circumcisions done for the personal preference (culture) or religion of the parent(s) deny the infant the basic right to respect and autonomy that is fundamental to Canadian law. Canadian law recognizes the individual person as an autonomous decision-maker. The individual's rights are guaranteed within the provisions of the Canadian Charter of Rights and Freedoms, Section 7 of the charter provides for the right to life, liberty and security of the person. Section 2(a) guarantees the right to freedom of thought, conscience and religion. Section 15(1) guarantees equality in protection and benefit of the law regardless of age.

Marie-Josee Bernardi, in Canadian Child Health Law, holds that: "the right to protection of the security of the person is one of the most sacred rights under common law. It includes the protection of the mental and physical integrity of the person as well as control over one's body."³

Children have the right to decide for themselves their beliefs and whether or not to participate in any associated procedures that affect their bodies. Any body altering procedures performed for religious reasons must be withheld until children are old enough to make their own decisions.

Abolishing non-medical circumcisions does not deny religious or cultural freedoms.

Circumcision may well be a procedure done illegally on unconsenting infants. Circumcisions done for the personal preference (culture) or religion of the parent(s) are not in the best interests of the infant. Abolishing non-medical circumcisions does not deny religious or cultural freedoms. Rather, it would result in the preservation and promotion of the right for every child to have and choose his own beliefs.⁴

Informed Consent

Circumcision is an issue of self-determination and autonomy.

Canadian law recognizes and affirms individual autonomy. Peter Singer and Sujit Choudhry note that:

"the fundamental principle in our society (is) that what people want for themselves takes precedence over what others think is best for them. This belief is the basis of the right of self-determination that underlies the doctrine of informed consent to medical treatment."⁵ This doctrine applies to proxy decision-makers, including parents who consent to procedures on their child. A decision to circumcise must be made in the best interests and must not be based upon the preference of others. It has already been demonstrated that circumcisions requested by parents deny the right to self-determination to which every child in Canada is entitled. Such circumcisions are not a medical procedure. Circumcision is an issue of self-determination and autonomy.

Nurses, however, do have an obligation to know about the process of informed consent. They must clearly understand their role in preventing helpless vulnerable patients from being subjected to inappropriate and harmful procedures under the guise of informed consent. How many nurses know that:

The prepuce is a highly specialized functioning part of the penis and is not just a tag of skin. Removal by circumcision is the amputation of a healthy body part resulting in removal of 25 percent of the sensory tissue of the penis.
Complications of circumcisions, from sepsis to haemmorhage or on occasion death, do occur in approximately two to 10 percent of all cases.
Fewer than five percent of intact (not circumcised) boys will experience a urinary tract infection, lower than the rate for non-circumcised girls.
The so-called relationships between circumcision and cancer of the penis, cancer of the cervix and sexually transmitted diseases have all been disproved, discredited, or are at best inconclusive. In all cases, alternative treatments that are less invasive, less traumatic and far more effective are currently available.
Not only is circumcision an extremely painful procedure with pain lasting several days, but there is an acknowledged lack of adequate research data on dorsal penile nerve blocks. The "alternative choice" of EMLA cream is not recommended for use on genital skin or mucosa, or on infants under six months.⁶

For those nurses who still hold the mistaken belief that informed consent is a physician's role, which releases nurses from any obligation to speak up, the RNABC Position Statement on Informed Consent states: "Nurses are ethically obliged to assess the patient's understanding of the proposed treatment and to inform the physician and/or the appropriate agency representative if there is reason to believe the patient has any misunderstanding regarding the nature, purpose, inherent risks or alternatives of his or her treatment."

It is also important for nurses to be aware that the Royal College of Physicians and Surgeons of Canada, in Informed Consent: Ethical Considerations for Physicians and Surgeons, has stated: "where parents or guardians request treatment that in the physician's opinion are contrary to the best interests of the patients...the physician should take whatever action is necessary to prevent harm to the patients; this may include recourse to the courts."

A recent Supreme Court of Canada decision placed the best interests of the child above parental rights.⁷ The Child Youth and Family Advocacy Act is becoming provincial law in order to facilitate advocacy services for children.

Circumcision is a nursing issue because nurses have a historical tradition of patient advocacy. If nursing is to remain a respected profession, nurses will add their voices to upholding and promoting the rights of children.

Contrast this statement with Canada's 1994 national nursing week theme "Nurses Make the Difference." Nurses can make that difference by speaking out. Why the reluctance?

Issues of dominance and submission, typical behavior of oppressed groups, have been deeply ingrained in nurses. Nurses perpetuate these attitudes in the nineties.^8,9 In an attempt to gain autonomy and self-respect, many nurses have adopted the values and attitudes of the dominant (physician) group, thereby becoming devalued sideline players in health policy decision-making. A lack of cohesion and support for other nurses was reflected in the obstruction of the New Westminster chapter's efforts to promote leadership in nursing.

Barbara Pesut argued that nurses do have power ready for their use, a power that is subtle, yet persuasive; "simply, the capacity to produce intended change."¹⁰

Nurses must not compromise their client responsibilities for a fear of controversy.

One way to exert power is by using personal power to develop empowerment in others, our clients. There is no client more in need of empowerment than infants. Many health care providers who continue the practice of non-therapeutic circumcision are themselves oppressed, men who have been circumcised or women who have husbands, brothers, or sons who have been similarly oppressed.

This article provides nurses with information to improve their knowledge and understanding about the nurse-patient relationship, and their role as advocates in maintaining and promoting patient autonomy. Nurses must not compromise their client responsibilities for a fear of controversy.

Pesut declared that more research regarding the nurse-patient relationship is an important step in the advocacy role. Anecdotal evidence abounds on the effects circumcision has on an unconsenting infant, some become adults who feel shame, humiliation, and anger toward those who allowed the procedure. Nurses need to develop a healthy skepticism of routine procedures and base their practice on sound nursing knowledge gained through expanded nursing research. This research must also include the legal and ethical factors impacting on practice.

Judith Oulton, executive director of the Canadian Nurses Association, recommends "an attitude of nursing knows no boundaries."

Society exhorts our youth to "just say no" to drugs, cigarettes and other evils around them. How can children be expected to speak with conviction and strength when nurses silently refuse to face controversy? Advocating for children's rights is a nursing responsibility. Circumcision is a nursing issue. Gretta Styles, president of ICN sums it up best when she says, "nurses are the ones to imagine it, to dream it, to do it."¹²

Iva Phillips, R.N., S.C.M. is a perinatal instructor with GVHS/Camosun College in Victoria. The author wishes to acknowledge the support and assistance of Bruce Holvick and Jean Church, members of the New Westminster chapter, in preparing this article.

References

1 Gordan A. and Collin J. (1993) Save the Normal Foreskin. BMJ 306 (2 January).

2 Nelson L. and Nelson R. (1992) Ethics and the Provision of Futile, Harmful or Burdensome Treatment to Children. Critical Care Medicine 20(3), 427-33.

3 Bernardi M. J. (1992) Children's Health in Constitutional Law. In B.M. Knoppers (Ed.) Canadian Child Health Law 112.

4 Kluge E.H. (1993) Female Circumcision: When Medical Ethics Confronts Cultural Values Canadian Medical Association Journal 148(2) 288-289.

5 Singer P. and Choudhry S. (1992) Editorial Canadian Medical Association Journal 146(6).

6 A suggested list to begin:

Bigelow J. (1992) The Joy of Uncircumcising! Hourglass
Howard C., Howard F. and Weitzman M. (1994) Acetaminophen Analgesia in Neonatal Circumcision. The Effect on Pain. Pediatrics 93(4), 641-46.
Poland R. (1990) The Question of Routine Neonatal Circumcision New England Journal of Medicine 322(18), 1312-15.
Thompson R. (1990) Routine Circumcision in the Newborn: An Opposing View Journal of Family Practice 31(2), 189-196.
Williams N. and Kapila L. (1993) Complications of Circumcision British Journal of Surgery 80(10), 1231-36.

7 Catholic Children's Aid Society of Metropolitan Toronto May 5, 1994.

8 Roberts S. (1983) Oppressed Group Behavior Advances in Nursing Science 5(4), 21-30.

9 Haddad A. (1991) The nurse/physician relationship and ethical decision making AORN Journal 53(1), 151-56.

10 Pesut B. (1994) Nursing's Power: It's How You Look at It Nursing BC 26(2), 18-19.

11 Oulton J. (1994) The Nineties: Nursing's Decade? The Canadian Nurse 90(2), 9.

12 Ibid

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