ethics of circumcision ethics of circumcision male circumcision is the surgical removal of the foreskin (prepuce) from the human penis. the ethics of circumcision in neonates and children is a source of much controversy. there is substantial disagreement amongst economists, bioethicists, theologians, philosophers, doctors, and political scientists over the practice, with little in the way of a general consensus beyond a belief that routine circumcision of neonates for health purposes is a cost-ineffective and ethically-problematic intervention in developed countries, and that circumcision on a consenting adult is a morally permissible action. positions taken on the issue are heavily influenced by prevalence in the given area, religion, and culture. some medical associations take the position that circumcision is an infringement of the child's autonomy and should be deferred until he is capable of making the decision himself. others state that parents should be allowed to determine what is in their best interest. medical bodies australia and new zealand the royal australasian college of physicians (2010) released a statement indicating that neonatal male circumcision is "generally considered an ethical procedure", provided that 1) the child's decision makers, typically the parents, are acting in the best interests of the child and are making an informed decision; and 2) the procedure is performed by a competent provider, with sufficient analgesia, and does not unnecessarily harm the child or have substantial risks. they argue that parents should be allowed to be the primary decision-makers because providers may not understand the full psychosocial benefits of circumcision. additionally, this procedure does not present substantial harm compared to its potential benefits, so parents should be allowed full decision-making capacity as long as they are educated properly. the statement also establishes that "the option of leaving circumcision until later, when the boy is old enough to make a decision for himself does need to be raised with parents and considered", and that "the ethical merit of this option is that it seeks to respect the child's physical integrity, and capacity for autonomy by leaving the options open for him to make his own autonomous choice in the future." canada the canadian paediatric society (cps) issued a position statement on september 8, 2015, which highlighted the ethical issue surrounding the child's inability to give consent. since children require a substituted decision maker acting in their best interests, they recommend to hold off non-medically indicated procedures, such as circumcision, until children can make their own decisions. yet the cps also states that parents of male newborns must receive unbiased information about neonatal circumcision, so that they can weigh specific risks and benefits of circumcision in the context of their own familial, religious and cultural beliefs. denmark the danish medical association (lægeforeningen) has released a statement (2016) regarding the circumcision of boys under the age of eighteen years. the organization says that the decision to circumcise should be "an informed personal choice" that men should make for themselves in adulthood. according to dr. lise møller, the chairwoman of the doctors' association's ethics board, allowing the individual to make this decision himself when he is of age respects his right of self-determination. the danish college of general practitioners has defined non-medical circumcision as mutilation. netherlands the royal dutch medical association (koninklijke nederlandsche maatschappij tot bevordering der geneeskunst) (knmg) and several dutch specialist medical societies published a statement of position regarding circumcision of male children on 27 may 2010. the knmg argues against circumcising male minors due to lack of evidence the procedure is useful or necessary, its associated risks, and violate the child's autonomy. they recommend deferring circumcision until the child is old enough to decide for himself. the knmg questions why the ethics regarding male genital alterations should be viewed any differently from female genital alterations, when there are mild forms of female genital alterations like pricking the clitoral hood without removing any tissue or removing the clitoral hood altogether. they have expressed opposition to both male circumcision and all forms of female circumcision; they do not advocate a prohibition of male circumcision, even though they argue that there are good reasons for it to be banned, and prefer that circumcisions be done by doctors instead of illegal, underground circumcisers. the dutch council on public health and care does not agree with the royal dutch medical association and states that they wrongly do not distinguish between male and female circumcision and that they do not take into account freedom of religion and the right of parents to raise their children according their own beliefs or convictions. nordic countries in 2013, children's ombudsmen from sweden, norway, finland, denmark, and iceland, along with the chair of the danish children's council and the children's spokesperson for greenland, passed a resolution that emphasized the decision to be circumcised should belong to the individual, who should be able to give informed consent. the nordic association of clinical sexologists supports the position of the nordic association of ombudsmen who reason that circumcision violates the individual's human rights by denying the male child his ability to make the decision for himself. the medical doctors at sørland hospital in kristiansand, southern norway have all refused to perform circumcisions on boys, citing reasons of conscience. united kingdom the medical ethics committee of the british medical association also reviewed the ethics behind circumcision. since circumcision has associated medical and psychological risks with no unequivocally proven medical benefits, they advise physicians to keep up with clinical evidence and only perform this procedure if it is in the child's best interest. they say the procedure is a cultural and religious practice, which may be an important ritual for the child's incorporation into the group. they recognize that parents have the authority to make choices for their child, and they emphasize it is important for parents to act in their child's best interest. they report that views vary in their community about the benefits and risks of the procedure, and there is no clear policy for this situation. commenting on the development of the 2003 british medical association guidance on circumcision, mussell (2004) reports that debate in society is highly polarized, and he attributes it to the different faiths and cultures that make up bma. he identifies this as a difficulty in achieving consensus within the medical ethics committee. arguments put forward in discussions, according to mussell, included the social and cultural benefits of circumcision, the violation of the child's rights, and the violation of the child's autonomy. adult circumcision in a paper published june 2006, the british medical association committee on medical ethics does not consider circumcision of an adult male to be controversial, provided that the adult is of sound mind and grants his personal consent after receiving all material information regarding the known risks, disadvantages, and potential benefits to be derived from the surgical operation. circumcision of adults as a public health measure for the purpose of reducing the spread of hiv also involves ethical concerns such as informed consent and concerns about reducing attention paid to other measures. according to the cdc website, research has documented a significant reduction of hiv/aids transmission when a male is circumcised. child circumcision in the same british medical association paper, circumcision of a child to treat a clear and present medical indication after a trial of conservative treatment also is not considered to be ethically questionable, provided that a suitable surrogate has granted surrogate consent after receiving all material information regarding the known risks, disadvantages, and potential benefits to be derived from the surgical operation. criticism and revision of bma statement the bma statement of 2003 took the position that non-therapeutic circumcision of children is lawful in the united kingdom. british law professors fox and thomson (2005), citing the house of lords case of r v brown, challenged this statement. they argued that consent cannot make an unlawful act lawful. the bma issued a revised statement in 2006 and now reports the controversy regarding the lawfulness of non-therapeutic child circumcision and recommends that doctors obtain the consent of both parents before performing non-therapeutic circumcision of a male minor. the revised statement now mentions that male circumcision is generally assumed to be lawful provided that it is performed competently, is believed to be in the child's best interests, and there is valid consent from both parent or the child if it is capable of expressing a view. american academy of pediatrics the circumcision policy statement of the american academy of pediatrics (enacted 2012, expired 2017) stated: "systematic evaluation of english-language peer-reviewed literature from 1995 through 2010 indicates that preventive health benefits of elective circumcision of male newborns outweigh the risks of the procedure." they wrote that the decision of whether or not to circumcise should be made by parents after considering the medical benefits and risks, along with "religious, ethical, and cultural beliefs and practices", and that the medical benefits are such that third-party payment for circumcision of male newborns is warranted. the policy statement also noted that the risk of complications is considerably lower when circumcision is performed during the newborn period, as opposed to when it is performed later in life. the american college of obstetricians and gynecologists had endorsed the american academy of pediatrics' circumcision policy statement. criticism the most recent american academy of pediatrics (aap) position statement on male circumcision (enacted 2012, expired 2017) has attracted significant critical comment, including from the aap itself. in a dissenting paper, frisch et al. (2013) write: "circumcision fails to meet the criteria to serve as a preventive measure for uti ... as a preventive measure for penile cancer, circumcision also fails to meet the criteria for preventive medicine ... circumcision for hiv protection in western countries fails to meet the criteria for preventive medicine ... circumcision fails to meet the commonly accepted criteria for the justification of preventive medical procedures in children." frisch et al. further comment: "the aap report lacks a serious discussion of the central ethical dilemma with, on one side, parents' right to act in the best interest of the child on the basis of cultural, religious, and health-related beliefs and wishes and, on the other side, infant boys' basic right to physical integrity in the absence of compelling reasons for surgery. physical integrity is one of the most fundamental and inalienable rights a child has. physicians and their professional organizations have a professional duty to protect this right, irrespective of the gender of the child." van howe and svoboda (2013) criticize the aap's statement because they believed that it failed to include important points, inaccurately analyzed and interpret current medical literature, and made unsupported conclusions. frisch et al. (2013) cited the difference of the aap's statements in comparison to other western countries, such as canada, australia, and various european countries. they attribute this to cultural bias since non-therapeutic male circumcision is prevalent in the united states. they also criticized the strength of the health benefits the statement had claimed, such as protection from hiv and other stis. the american academy of pediatrics responded that because about half of american males are circumcised and half are not, there may be a more tolerant view concerning circumcision in the us, but that if there is any cultural bias among the aap taskforce who wrote the circumcision policy statement, it is much less important than the bias frisch et al. may hold because of clear prejudices against the practice that can be found in europe. the aap then explained why they reached conclusions regarding the health benefits of circumcision that are different from the ones reached by some of their european counterparts. american medical association journal of ethics in august 2017, the american medical association journal of ethics featured two separate articles challenging the morality of performing non-therapeutic infant circumcision. svoboda argues against non-therapeutic circumcision. he states that this decision should be considered in the context of benefit vs risk of harm, rather than simply risk-benefit due to the non-therapeutic nature of the procedure. he states that benefits do not outweigh the risks, and also claims that foreskin removal should be considered a sexual harm. he also goes on to conclude that non-therapeutic circumcision largely violates the physician's duty to respect a patient's autonomy since many procedures take place before a patient is able to freely give consent himself. reis and reis's