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A Butcher's Approach

Ballard, Dustin MD

doi: 10.1097/01.EEM.0000403754.13983.0f
Screened & Examined
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There's a truly heinous procedure, a cruel punishment wrought against newborns. Virtually every newborn in this country is subjugated to this bloody assault, one that severs an attachment with the mother. What is this horrific act, and how can it possibly be legal? It's the butchering of the umbilical cord after birth.

OK, butchering isn't really a fair description. The clamps are sterile, and the procedure is usually not messy or at all painful. And I think we can all agree that, while cutting the umbilical cord may be an invasive procedure, it is nonetheless necessary. It would be ridiculous to forbid cutting an umbilical cord. Not so far-fetched is the proposed ban of another widespread newborn procedure — circumcision. This procedure is, of course, not a standard ED one, but the effort to sanction it is one that should attract the scrutiny of all health care providers. We'll come back to this point, but first let's explore the sensitive issue at hand.

You may have heard about the recently certified resolution that will appear on the San Francisco ballot this fall that would make the “genital cutting of male minors” illegal and punishable (for practitioners such as physicians and mohels) with a $1,000 fine or up to one year in prison. The initiative would make it unlawful in the city “to circumcise, excise, cut, or mutilate the whole or any part of the foreskin, testicles, or penis of another person who has not attained the age of 18 years.” The sponsors have obtained the 7,700 city resident signatures necessary to place this on the ballot, and the controversy is attracting comment from numerous cultural and media silos (including a rather distasteful comic, Foreskin Man, in which the villain is a scissors-wielding rabbi.)

Certainly, there are numerous ways to skin this story (if you'll pardon the pun), but fundamentally, this is an ethical question. As we all know, one of the core principles of biomedical ethics is autonomy — the ability of the patient to make informed decisions about his body and medical care. This is an essential principle. Without it, the experimental abuses of Nazi Germany and Tuskegee, AL, might someday be relived. Newborn babies cannot, of course, make any decisions. They know how to cry, feed, sleep, and fill a diaper. That's about it.

Making an informed decision about “genital cutting” is not in their wheelhouse so this decision falls to others. In the vast majority of instances, a child's parents are the appropriate decision-makers because they are the progenitors of the new life and most directly affected by its immediate fate. The rights of parents have not been explicitly defined. They are neither wielded through surrogacy nor autonomy but a combination of the two; let's call it progenitonomy (the rights under the law of the progenitor).

Such rights cannot, of course, be absolute. We do not allow, for instance, Jehovah's Witnesses to deny their children life-saving blood transfusions. And the news is rife with other circumstances where the state must step in to guarantee the health of a child whose parents or guardians have abdicated their progenitorship. Is the circumcision of newborn males such a situation? I think most of us would agree it is not. (Not including, of course, the 7,700 people in San Francisco.) But in the name of informed debate, let's examine the major risks and benefits of “genital cutting of male minors.”

Benefit #1: Protection against infection including urinary tract infections in infants, infections of the glans of the penis, and sexually transmitted diseases such as HIV and HPV. It's well established in the medical literature that uncircumcised men are at increased risk of infection due to the moist, germ-friendly environment under the foreskin. Note also that the infection protection that circumcision provides is valuable not just to the individual and his sexual partners but also to the public health at large. The low rates of circumcision in Africa are thought to have contributed to the AIDS epidemic, and multiple studies have indicated that circumcision should be considered an effective “surgical vaccine” for HIV.

Benefit #2: Protection against penile cancer. Once again, this is well established. And while penile cancer is rare, it is worth noting that newborn circumcision provides 100% defense against it. There is, of course, an additional 100 percent protection against phimosis and paraphimosis.

Benefit #3: Cultural and religious sensitivity. There is no denying that circumcision is of great importance to Jews and Muslims. It may also be important to some nonreligious parents who live in areas with high rates of circumcision. But let's be clear: There are limits to a “cultural” benefit. Most would agree that forced female circumcision during the adolescent years goes well beyond any defensible level of moral relativism.

What then about the risks or potential harm? Yes, circumcision is a painful procedure. By measuring heart rate and stress hormone release (cortisol) in infants, this somewhat obvious observation has been scientifically validated. But, then again, I can't imagine that penile cancer is pain-free either. And nowadays, various forms of anesthesia are routinely used for the procedure that should mitigate concerns significantly. Complications of newborn circumcision are very rare, occurring much less than one percent of the time (actually 0% in a large Kaiser study published in 2006), and mortality is virtually unheard of (besides a few reported cases of in-the-home deaths of undiagnosed hemophiliacs). Anecdotally, uncircumcised men are more prolific in the bedroom, although I am not aware of any scientific evidence supporting this claim. In terms of potential harm then, circumcision is much less risky than other common parental decisions, such as foregoing routine vaccinations and placing earrings in youngsters.

So where does this lead us? Circumcision is a common procedure that is safe yet potentially painful. It has some long-term health benefits, but not enough to consider it a recommended procedure on a medical platform alone. There is some possible harm, but it is quite minor, and the real harm (for some) seems to be in the imagery it evokes. Ultimately, though, there does not appear to be any basis to deny parents the ability to make this decision for their child based on their own beliefs and circumstances. To punish practitioners for carrying out the progenitor's circumcision request, to quote Laurence Baskin, MD, the chief of pediatric urology at the University of California-San Francisco, is “a bunch of nonsense.”

If you've made it this far, you may still be wondering how the circumcision debate affects emergency physicians. Here's how: This ill-conceived initiative proposes to punish practitioners for carrying out the medical requests of parents. This is an affront to the patient-doctor relationship that should concern all providers. The slippery slope of this type of approach is worrisome. Emergency departments are already highly regulated; we can be fined for not appropriately transferring patients or not protecting their health information. In some locales, we can be penalized for not washing our hands often enough or discharging a homeless person without having first found him a new home.

There are certainly valid rationales for these restrictions, but they nonetheless affect our practice, sometimes negatively. Consider being penalizing for ordering a generally considered safe but theoretically risky procedure, such as a CT scan at the request of a child's parent? Sound farfetched? Perhaps, but if you were to follow the logic of the proponents of the San Francisco ban, maybe it's not. Regardless of your opinion on the merits of circumcision, the San Francisco initiative is not a healthy one. In fact, it is, quite simply, a butcher's approach to ethics and medicine.

Comments about this article? Write to EMN atemn@lww.com.

Dr. Ballardis an associate emergency physician at Kaiser-Permanente in San Rafael, CA, and the chair of the CREST ED Research Network. His writing credits include co–authorship with Angela Ballard of the award-winning travel narrative A Blistered Kind of Love: One Couple's Trial by Trail (Mountaineers Books, 2003) and authorship of The Bullet's Yaw (IUniverse, 2007). Dr. Ballard writes a biweekly-medical column for the Marin Independent Journal, which he posts on his blog:http://incisionanddrainage.blogspot.com

Read EMN's article about the Florida law that could penalize physicians for asking patients if they own a gun. http://bit.ly/GagGun

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