See also: Global Survey of Circumcision Harm (2012 to present)

In my ethical reflecting in this paper I will rely mostly on the thought of Immanuel Kant to support my position that it is the rights of the child that always should be first considered. Moreover, I will examine four current moral tensions related to circumcision and here I will introduce other ethical opinion such as John Rawls' notion of "justice as fairness" as a way of understanding and hopefully resolving these tensions.

In my review of the literature, I have found a tremendous wealth of information on the topic of male circumcision. There are books, articles, pamphlets and videotapes condemning the practise. There are web pages on the Internet as well as advocacy groups whose membership is made up of circumcised men who work vigorously to publicise their view that infant circumcision is a serious form of child abuse.

This summer (1996) an international symposium on sexual mutilation of infant male and female children will be held in Switzerland to focus world attention on the practise of forced removal of healthy genital parts and those countries that practise it.

There are groups such as Nurses for the Rights of the Child who feel that neonatal circumcision violates a male's right to an intact body. These groups provide information and support for parents and nurses as well as acting as advocates for infants and children. N.O.R.M., the National Organization of Restoring Men, which supports men attempting non-surgical foreskin restoration, has local chapters in most Western countries. The sheer number of men willing to go to the trouble and pain of surgical or non-surgical restoration indicates that circumcision has harmed men in an unacceptable way. NOHARMM, the National Organization to Halt the Abuse and Routine Mutilation of Males, is a group of men who educate the public about the value of normal genitalia and expose circumcision as a violation of human rights. Tim Hammond, who is the founder of NOHARMM, has produced the award winning documentary film: "Whose Body, Whose Rights?" which dramatizes all the central moral issues surrounding infant male circumcision.

There are lawyers who specialize in law suits involving forced circumcision. D.O.C., Doctors Opposing Circumcision, promotes human rights principles in their practises as well as educating health professionals about the rights everyone has to intact sexual organs. I have spoken by telephone with nurses in Canada and the United States who have lost their jobs for educating parents of infant male children about circumcision.

Marilyn Milos of NOCIRC, the National Organization of Circumcision Information Resource Centers,  is one such nurse. She has spent a decade organizing educational forums about circumcision as well as championing human rights. Clearly circumcision is a bioethics issue that affects nurses.

As a medical procedure circumcision is not defensible. It is the amputation of healthy tissue with no compelling medical reason. As with all surgical procedures there is inherent risk, but what level of risk is acceptable in a procedure that is not necessary medically?

There is a great deal of ignorance even in the medical community about the foreskin and its function. The foreskin protects and preserves the sensitivity of the glans, provides erogenous sensation and aids in coital mechanics. When normal, healthy tissue is removed, sexual function is also altered. Penile changes occur after circumcision, such as thickening of the glans. There is no empirical evidence that shows benefits to sexual performance. The Canadian and American pediatric societies both state in their literature that it should not be routinely performed. D.O.C. (Doctors Opposing Circumcision) states that,

The human penis is designed correctly the way it comes into the world with its foreskin intact, that a male's possession of his own penis, including the foreskin, is his inviolable birthright, and that a child's chances for health and happiness throughout his life are greater by far if he is allowed to keep all of his penis.(NOCIRC, p.2)

Thousands of boys a day are circumcised in North America. The medical and nursing community are not for the most part being scientifically and ethically critical of this procedure. The term critical is an important one. It is usually associated with negation, rejection, disputing, but its intrinsic meaning is something different. Essentially it means putting something to open scrutiny, to analyze the worth or value of something. Another meaning rooted in its usage in classical Greece is the idea of change. A crisis is a turning point, so a critique of something or critical thinking places an idea or convention or rule at a turning point. Should a convention, for example, be kept and all the tradition that goes with it; should it be modified; or should it be discarded totally? These are the sort of options in critical thinking. Socrates said: "The unexamined life is not worth living." Critical thinking is essential to any human context, but especially in the medical context where the issue of human good is present in every protocol, every diagnosis, every hospital policy, every conversation between patient and health care professional. Bandman and Bandman have some relevant things to say about critical thinking:

This critical thinking process consists in assessing the data that surrounds disputes, examining assumptions, generating and testing inferences,and in forming and continuously revising our judgments of what we may reasonably regard as credible and justifiable. (Bandman & Bandman, p.290)

The health care context and specifically the hospital context should allow for on-going critical thinking by professionals and representatives of the wider community to discuss all practises and policies whether they be conflictual or not. That should be the purpose of ethics committees. Circumcision is one the most conflictual issues confronting the hospital context today; it demands the application of critical thinking to address the growing concern that it is an infringement on all that hospitals (hospices) and health care systems have stood for.

To begin my ethical discussion I would like to start with the stress that Kant and I believe Aristotle places on acts being good only if they are good in themselves. In The Foundations of the Metaphysic of Morals, Kant starts his exploration of the nature of morality by asserting:

Nothing can possibly be conceived in the world, or even out of it, which can be called good, without qualification, except a Good Will. (Pojman, p.256)

Talents, skills, and wealth might be desirable and good , but they can be abused, so they are limited goods. Moreover, not even the good consequences of a well meant act are unconditionally good because altruistic acts could be done out of some questionable motivation or from external compulsion. The Good Will is not good because it is useful or popular; it is good like a jewel where its value lies totally in itself. Though Kant was a deist and not formally attached to any expression of Christianity, in locating the source of the good in the Will, he places himself squarely in the Judaeo-Christian tradition where the will of God is seen as the source and the purest expression of the good. In his writings on religion, Kant, in fact, sees the (human) Good Will as rooted in a transcendent cosmic will. His often expressed statement: "Two things fill my heart with wonder, the starry skies above and the moral law within," gives expression to the religious roots of his understanding of human morality.

This doesn't mean that Kant's ethical theory gives little worth to the human role in discovering what is good. Though Kant is classified as deontologist, an ethical thinker who sees the moral life in terms of laws and oughts, what one ought to do is not revealed by God, but is discovered by human reason. Kant was a man of the Enlightenment, so he believed reason could enable one to discover the central moral laws of the universe just as it could aid in discovering the laws of physics or astronomy or biology. He thus saw his moral system very much as a science, although in practising it on a daily basis there might be some art to it as well.

Having located the source of the good in the Good Will, Kant then explores a second dimension of the good. He makes a fundamental distinction between hypothetical and categorical imperatives. A hypothetical imperative is experienced as conditional; it depends on how one feels about the end to be pursued. For example, a parent of a toddler might not respond to the call of their child in the middle of the night because they just don't feel like getting up or because they are still mad at him for destroying their prized tulip bed last night. A hypothetical imperative like this is experienced as "may be" or "one should but can't right now." A categorical imperative carries a different weight. The imperative is experienced as an absolute command. One must respond to a child's cry even though one does not want to because it is the right thing to do. Furthermore, one must respond without hesitation to one's child's call, not because it will bring a sense of pleasure of being a good mother, but again because this is the only course of action that is right.

Closely connected with the notion of categorical imperative is Kant's notion of duty. Only acts done from duty are always good because duty ensures that one will respond to the categorical "ought." Relying on one's inclinations or feelings no matter how admirable is not reliable according to Kant. Even a sense of friendship or sacrificial love is not any guarantee of moral consistency - only duty guarantees this.

This is where Kant differs fundamentally with the tradition of ethics started by Plato and Aristotle. The tradition known as teleological centres the moral good in ends that are attractive and desirable. Any rational person would choose to follow virtues like happiness. However, Kant like St.Paul, believed that, left to choice, human beings would not always choose to do the good thing, that the source and guarantor of the good had to be rooted in something more trustable, and for Kant this meant a sense of duty.

Circumcision of infants is a form of exploitation
and a rejection of the fundamental worth of the infant.

Max Charlesworth, in his Bioethics in a Liberal Society, sees this formulation of the Kantian ethics as the basis of the liberal society:

For Kant the autonomous moral agent or human person is deserving of unconditional respect and there is no more valuable thing in the world than a human person exercising the freedom to choose and follow out her or his own destiny. (Charlesworth, pp. 167-168)

I have expounded on the Kantian ethic at some length because I believe it provides us with a profound understanding of the nature of the moral good and thus it seems to serve as a valid basis for developing an ethical position towards circumcision. The male infant, though at the beginning of its mental and physical development, deserves to be treated as an end and not as a means to satisfy the prescriptions of a religion or the preferences of parents or the financial goals of the physician. Circumcision of infants is a form of exploitation and a rejection of the fundamental worth of the infant. Given Kant's stress on reason and choice, to make decisions for a child, even though there might be good intent, still infringes on the basic worth of the child; by denying the infant's right to make a rational choice when it is of age to do so. Kant would support the procedure of informed consent because reason demands that there be a priori knowledge of what is going to happen so that a rational, knowledgeable choice can be made. Kant's first formulation of the categorical imperative is also germane to this discussion. One cannot espouse the cause of human rights such as the rights to life, liberty and happiness for adults but then deny these to children or to any vulnerable group such as the frail elderly or to victims of AIDS. If the Hippocratic Oath entails respecting the life and body of the patient, then exceptions cannot be made. The notion of duty is critical too. Physicians are likely to have attachments to religions and to scientific biases, but if the primary moral aim of medicine is to respect the person, and this includes the body of the patient, then these personal biases, religious beliefs and feelings have to be suspended and a deeper sense of moral duty or conscience should take hold to guarantee the realization of a more universal good.

I need to mention that in the field of Bio-Ethics today there is a vigorous debate about using one model of ethics to deal with a complex moral issue like circumcision. David De Grazia is a leading American bio-ethicist who teaches philosophy at George Washington University in Washington, D.C.

In a recent article, he writes:

Bioethical theory does not seem to be advancing much today. Some have suggested that this sluggishness is due to the quality or the dearth, of scholarship in relevant theoretical areas. I suggest that the difficulties lie with leading models themselves, or perhaps with the way they are understood. (De Grazia, p. 512)

These leading models, all of which have ancient roots, are: deductivism, casuistry and principalism. De Grazia suggests as an alternative specified principalism, which appears to me to be similar to the situation ethics of Joseph Fletcher. All this debate in the field of bioethics seems to be a reflection of a larger debate going on today in academia between structuralists and deconstructionists about the validity of the different ways scholars in all fields from bio-chemistry to philosophy interpret reality. My own tendency is to side with the structuralists who have a long history going back to Aristotle.

Kant fits into the structuralist position and the deductivist camp cited by De Grazia. However, I think it wrong to see Kant as an inflexible legalist, as is too often the case. Kant's categorical imperative, which commits us to treating human beings as ends, would it seems to me over-ride any unchangeable commitment to any one principle or value, such as the notion that in every life and death situation in a hospital, people must be kept alive because prolonging life is absolute moral imperative. This does not mean that Kant can be seen as a situationalist or a casuist because both would see the moral ought as conditional or hypothetical. It seems to me that Kant would be very sympathetic to the writing of another man from what used to be Koenigsburg, namely, Jurgen Habermas, who seems to be arguing in a highly convoluted way in his writings that in dealing with moral issues all we have to rely on is reason and good will. Kant, then, in my opinion, gives us an ethic which acts as a sort of beacon which can help us negotiate the dark maze of a moral issue with some hope of approaching the true and right response.

Kant, however, lived in the eighteenth century, so he was not familiar with some of the specific issues that would emerge in the world of the late twentieth century. He would not have imagined the complex ways in which technology and science have transformed human life and thus created very difficult moral issues. So for the rest of my paper I would like to look briefly at four tensions that exist perhaps more generally in the field of bioethics and more specifically in the circumcision of male infants.

1. Paternalism versus Autonomy/Informed Consent

The tension between paternalism and autonomy quite well: Regardless of how necessary the pediatrician and the parents might have judged the intervention to be, all such interventions undertaken for their own good - over their persistent objection - are experienced by children as disrespectful to them as evolving persons. (Pediatrics, p.981)

The Canadian Charter of Human Rights requires that a patient's expressed wishes may not be over-ridden even if it is in his or her best interests that they should be. One only needs to witness a male infant circumcision procedure to understand what the infant wishes. The right to self determination underlines the notion of informed consent. The infant being circumcised is denied his right to give informed consent. He is too young to state his own wishes and no one should pretend to assume what those might be. Given this right to self-determination, that even infants have, it seems to me that the only moral option is to wait until a child is of age so that he can make an informed decision.

2. Conventionalism versus Human Rights

Over 90 per cent of Jewish male infants are still circumcised, even though half of the parents involved are no longer practising Jews. (Awakenings, p.1) The practise of circumcision is deeply rooted in the Jewish faith. The seventeenth chapter of Genesis states that all male Hebrew children must be circumcised by the eighth day. Circumcision served much the same role that infant baptism has served in the Christian faith, as a kind of initiation rite. As contemporary Jewish educator, Miriam Pollack, has put it: "Circumcision tears the child away from its mother and bonds it with the father or the male world. As such, circumcision helped prop up patriarchy." (Videotape: Whose Body, Whose Rights?) Pollack goes on to say that the tradition of male circumcision pre-dates the Exodus event or Mosaic Judaism and was imported into Judaism from a more warrior orientated society, thus destroying matrilineal conventions that were inherent in early Hebraic culture. "Where is respect for the sacred in circumcision of infant males?" Pollack asks. "Where is the respect for the sacredness of a mother's feelings to love and protect her newborn child?" (Videotape: Whose Body, Whose Rights?) For Pollack, male circumcision is not needed to maintain the Jewish faith. It is not intrinsic to the faith.

In a multi-cultural and multi-faith country like Canada, all religions need to be respected, but if crimes are committed and the rights of children to choose for themselves are not respected, then religions should have to reconsider which of their practises do not respect basic human rights. Organized religions, and particularly various Christian denominations, feel they have a right to constantly critique the policies and practises of a government or state. Why then should not governments or the state have a right to critique the actions of churches or faiths like Judaism? Circumcision as practised in Judaism needs to be critiqued by the state because it is an act where the body of the infant is abused and the right to choice of the infant is disregarded.

3. The Rights of Children versus the Rights of Parents

My position, which I think is evident by now, is that circumcision is a form of child abuse. It is a mutilation of a minor for non-health related reasons without the consent of the child. Margaret Somerville, a leading Canadian bio-ethicist and director for the McGill Centre for Medicine, Ethics and Law, in a letter to the Canadian Health Minister, Pierre Blais, argues conclusively that male in infant circumcision is a form of child abuse.

I disagree that male circumcision involves only de minimis harm..... An analogous example may make this clear. Let us suppose that there is a new group in Canada which decides that, shortly after birth, the right earlobe of all children born into the group will be removed in order to identify them as belonging to that group. I believe that this would be prohibited under our Criminal Code as it currently stands. It would involve more than de minimis harm and as such it would not fall within any social exception and would be regarded as contrary to public policy. It would be an assault with wounding which was not justified by any therapeutic aim, the only justification which would seem to be potentially relevant. And, yet, this procedure may be less harmful to the children subjected to it than is male circumcision to the children subjected to that, which indicates that de minimis harm is not an appropriate justification of male circumcision. (Somerville: Letter to the Honourable Pierre Blais, p.3)

The Canadian Charter of Human Rights, Section 7, provides for the right to life, liberty and security of the person. Marie-Jose Bernardi is a Canadian Child Health educator. She states that "The right to 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."(Bernardi, p.112) In a society where we give much attention to the rights of the unborn fetus, we show at the same time a surprising lack of compassion for infants once they are born.

Bernard Dickens, a professor of law and medicine in the University of Toronto, writes:

The legal power of parents regarding their children, and of relatives or other legal guardians regarding the chronically incompetent, exists for the purpose of permitting parents or guardians to discharge their legal responsibilities. Ideally, the wishes of dependent persons will be served, even if they are retarded or young. Where parents cannot serve the wishes of their charges, however, they must serve the interests of their charges and not their own interests. Thus, powers cannot in principle be applied for non-therapeutic purposes, desired by the guardians. (Dickens: p.48)

I believe Rawls' notion of "justice as fairness" gives forceful ethical support to my point that parents acting as proxy for their infants do not have the right to make decisions about a non-therapeutic medical interventions on their child's behalf. According to Rawls:

All social values - liberty and opportunity income and wealth, and the bases of self-respect - are to be distributed equally unless an unequal distribution of any or all of these values is to everyone's advantage. (Pojman, p.635)

According to Rawls, in democratic countries we try to give extra rights to groups that are vulnerable. We do this in Canada with the elderly who monopolize 45% of the health care dollar even though they represent just 12% of the population. And it is in our self-interest to do so because we all will be old some day and will expect the same extra rights to income, opportunity and respect. Is it not then the same with children? We give them extra care as parents, and surely extra protection because they are vulnerable, and if we were in their position to choose as infants, we would want to have the opportunity choose. The literature on the attitudes of men who are now adults but who were circumcised as infants state overwhelmingly that they would not have chosen to be circumcised as infants, if they had had the choice. To be fair to the infant in Rawls' sense of justice, then, parents do not have any right to make the decision to circumcise or not to circumcise on behalf their children. It is the moral responsibility of parents to protect and nurture their children, but not to control and determine what and who they are and shall become.

4. Physicians Obligations versus The Wishes of Parents

What if the parents want their child circumcised? The medical community, both physicians and nurses, do not have to be party to this request. Eike-Henner Kluge, one of Canada's most respected bio-ethicists writes:

No one has a duty to do something that is unethical. This is not a matter of personal values, but of basic, universal, and fundamental ethical principles that apply to all people. (Kluge, p.289)

Nelson and Nelson state:

It is inconsistent with a child's best interest to impose a burden disproportionate to the benefit achieved or to demonstrate disrespect for a child's dignity and worth as a person. (Nelson and Nelson, p.428)

Paul Ramsey, one of the great figures in the development of Bio-Medical ethics, says physicians must always be attentive to "the patient as person." Physicians cannot accept the principle of respect for people and their needs as outlined in all the great medical codes of ethics like the Hippocratic Oath and the Nuremberg Code, and then perform procedures they know to be medically inappropriate, demeaning and harmful only because they do not want to offend a specific cultural sensitivity or the paternalistic attitude of parents who want to do what THEY think is best for their child. Circumcision is demeaning to an infant and in Kantian terms it is wrong because it is not an expression of a Good Will which would always protect the long term interests of the infant-person who is just as much an end as the parent.

CONCLUSION

I think it more pertinent in my conclusion to state briefly what I have learned from doing this paper rather than to summarize my position. First of all, I have learned how much this practise has bothered me for the past twelve years in my practise as an obstetrics nurse. The paper has given me a chance to articulate in a formal way my feelings. But secondly, it has enabled me to apply theory to practise. In my undergraduate days, I took several courses in religious studies and ethics and never really saw then how important it is for professionals to be aware of and perhaps rethink their moral values. In a radically pluralistic society like Canada, we need to be aware of what we believe and be willing to dialogue with, or as Canadian ethicist Fred Bird has suggested, have conversations with others of differing value systems to ensure that the good is done. This process of dialoguing is particularly critical in hospitals because doctors for the most part, who are mostly male in my hospital context, are not willing to look at the more nurturing feminine virtues that have been emerging in my society thanks to the women's movement and researchers like Carol Gilligan. Thirdly, the controversy surrounding infant male circumcision, and the seeming unwillingness to discuss it in a public forum, seems to me to represent the long-standing taboos associated with human, and particularly male, sexuality. As Freud pointed out, men sublimate their sexual feelings and in the process reject the development of mature attitudes towards their sexuality and the body parts that express this sexuality. Fourthly, and finally, I now see the need to connect theory with practise; ethics should lead to politics. Through telephone calls, letters and messages on E-mail, I have become aware of the vast network of men and some women who are courageously speaking out against the practise of the circumcision of infant males so that there might be justice for the newly born male. Let me end by citing some statements that represent this cause.

Since circumcision is not medically warranted, has no significant medical benefits, is painful because it is performed without anesthesia and leaves a wound in which urinary salts burn, carries significant risk of surgical complications, including death, and deforms the penis, it would seem that as a non-accidental physical injury, it is properly included in the definition of child abuse. (William Brigman, p.337)

Society cannot hear what men do not say, Men cannot say what we don't feel; and we can't get in touch with our feelings, until we raise our awareness of an issue. (Warren Farrell, Awakenings, p.1)

Where is the respect for the sacred in the feelings of a mother to protect her newborn child? (Miriam Pollack, videotape, Whose Body, Whose Rights?)

Beauchamp, T.L. and Childress, J. Principles of Biomedical Ethics, Fourth Edition, (New York: Oxford University Press, 1989)

Beauchamp, T.L. and Walters, L. (editors). Contemporary Issues in Bioethics, (Encino, CA., Dickenson, 1978)

Charlesworth, Max. Bioethics in a Liberal Society, (Melbourne:Cambridge University Press, 1993)

Gilligan, Carol. In a Different Voice: Psychology Theory and the Development of Women, (Cambridge, MA: Harvard University Press, 1982)

Kluge, Eike-Henner. Biomedical Ethics in a Canadian Context, (Scarborough, ON: Prentice-Hall, 1992)

Pojman, Louis. Ethical Theory: Classical and Contemporary Readings, (Belmont, CA: Wadsworth, 1995)

Ramsey, Paul. The Patient as Person: Explorations in Medical Ethics, (New Haven: Yale University Press, 1974)

Singer, Peter. Practical Ethics, Second Edition, (Cambridge: Cambridge University Press, 1993)

Articles

Hammond, Tim. "Awakenings: A Preliminary Poll of Circumcised Men" NOHARMM (National Organization to Halt Abuse and Routine Mutilation of Males) San Francisco, CA., 1994.

DeGrazia, David. "Moving Forward in Bioethical Theory: Theories, Cases, And Specified Principalism," The Journal of Medicine and Philosophy, No. 17, 1992.

Denison, J. "Minors and Health Care" Whose Consent and When?" Health Law in Canada, 1980.

Denniston, G. "Unnecessary Circumcision," The Female Patient, Vol. 17, July, 1992.

Dworkin, G. "Paternalism," Encyclopedia of Ethics, Lawrence Becker and Charlotte Becker, eds., Vol. II (London: Garland Publishing, 1992).

Committee on Bioethics-American Academy of Pediatrics. "Informed Consent, Parental Permission, and Assent in Pediatric Practise," Pediatrics, Vol. 95, No. 2, February 1995.

Kluge, Eike-Henner, "Female Circumcision: When Medical Ethics Confronts Cultural Values," Canadian Medical Association Journal, January 1993.

Fetus and Newborn Committee, Canadian Paediatric Society. "Neonatal Circumcision Revisited," Canadian Medical Association Journal, Vol. 154, no. 6 March 15, 1996.

NOCIRC Newsletter, Spring 1994, Spring/Summer 1996.

Phillips, Iva. "Advocacy: Rhetoric or Practise," Nursing BC. August-September 1994.

Somerville, M.  Letter to the Honourable Pierre Blais, Minister of Justice and Attorney General of Canada, January 28, 1993.

Videotape

Whose Body, Whose Rights? Dillonwood Productions, 1995 (VideoFinders 1-800-343-4727).