A response to the Finnish Medical Association’s opposition to circumcision

Having read the Finnish Medical Association’s working group report on circumcision and its subsequent opposition on the grounds of ‘medical ethics’, I wish to present a critical view of their position, and hopefully to broaden this debate a little more. Their statement can be found here.

I will group my main criticisms under five separate points.

1) Their objection is based they say on ‘medical ethics’ alone. In other words, the broader ethics of ‘religious freedom’ carries little weight in their deliberations. Indeed, they specifically cite the WWII Nuremberg trials and the subsequent World Medical Association’s right to follow medical ethics at all times even when in conflict with local laws and customs, which was an attempt to avoid medicine ever again being used to experiment unethically on humans, as was done by the Nazis.

By medical ethics, they mean to consider the issue entirely from a strict appraisal of any potential risks to the child and any well proven health benefits. As the evidence on health benefits is not conclusive, they cannot be taken into the ethical considerations, while the risks will include also those risks were the practice to be done in a backstreet barber’s shop with a filthy shaving blade.

I think Lääkäriliitto have made an unusually narrow interpretation of medical ethics and indeed of ‘health’. Health should and normally does include mental health, though this aspect is only considered by them from the point of view of the potential negative experiences (ill-health) of living with male circumcision and not from any positive social aspects such as identity and familial affirmation. While they are right to be concerned with negative effects, they must on the same grounds (mental health) give due consideration to those who consider it essential to their identity.

It’s worth pointing out that medical ethics in the general sense seeks to establish whether there is sufficient justification for a procedure or experiment involving humans, but they are not always justified on the basis of ‘additional’ health benefits alone. Social and economic aspects are quite normally part of the deliberations of ethics committees. A new drug that replaces an existing drug may bring no greater expected health benefit, but is either a cheaper drug (or often more expensive) or has a different mode of action. Likewise, an ethics committee may give consent for a clinical trial in order to establish ‘no significant risk’, while itself being a risky endeavor for the participants. It is clearly misleading to give the impression that medical ethics starts from a position that ‘no health benefit’ requires there to be ‘no risk’ for a procedure to be sufficiently justifiable, at least in principle. Let’s at least make that point clear.

2) although they claim to approach the matter purely from the point of view of medical ethics, they do seek support from the Finnish constitution and various other international rights frameworks. They therefore interpret the right to ‘integrity’ to mean physical integrity in a very strict sense, and interpret circumcision to be a violation of that integrity.

However, I would say that it is stretching the concept of ‘integrity’ to suggest a smaller foreskin constitutes a breaking of the fundamental integrity of the human form. At the very least, we would say that the issue of ‘integrity’ here is open to debate. It surely lies in the grey semantic area that comes with a word like ‘integrity’. For me, removing a leg, maybe, or an eye, or a clitoris would compromise integrity.

That it is a permanent alteration of the body is clear, but as the length of foreskin is subject to natural variation, from very little to very excessive, I would say that it is in medical terms a cosmetic alteration and therefore not a gross violation of the basic integrity of the body. Indeed, doctors have no instrinsic objection to doing cosmetic surgery on aesthetic grounds alone, although the issue of consent remains. The issue of ‘integrity’ is perhaps less significant than it’s made to sound, though.

If however we take their strict definition of integrity to its logical conclusion we would reveal serious inconsistencies with current practice. In many ‘cosmetic’ surgeries, carried out legally on children by health professionals, healthy flesh or body tissue is likewise removed, in procedures such as octoplasty (ear pinning), which involves general anaesthetic, orthognathic surgery (removal of health jaw bone), adenoidectomy (involving full anaesthesia) with all the attending risks. Even giving a blood sample can, using the same strict criteria, be considered to be a similar unjustifiable risk in some instances, if the worst case scenarios are brought into play and any uncertain health benefits are ignored.

Most significantly though, under this criteria, abortion would be condemned as unethical.

In abortion for social reasons (approximately 9000 a year in Finland, 90% of all abortions), perfectly healthy tissue is removed from the woman without the ‘consent’ of the fetus at the sole request of the parent.

If the lääkärilitto wish to go down this road in their strict interpretation of medical ethics, then it should surely come out in opposition to abortion? Indeed, the ethical implications are far more serious, in that an embryonic life is ended in the procedure.

The Finnish Medical Association’s stance on abortion is far more lenient (or should we say more cognizant of the social aspects).

The physician respects all forms of life. Different societies have in laws or otherwise defined at which stage the life of an embryo or foetus is protected like the life of a new-born baby. From the medical point of view this stage is at latest reached when the foetus could continue life outside the mothers womb.

This wording leaves the door open for abortion, although many pro-life campaigners cite the Finnish position as being fundamentally pro-life. But specifically, the Association does not call on doctors to not perform abortions, and neither do they tackle the issue of abortion as being the removal of healthy tissue at the request of the parent and without consent to the living embryo thus affected.

So, given the much more grave implications with abortion, why does the Association decide on balance to come out against circumcision in such strong terms while leaving a large degree of margin in dealing with abortion? Institutional racism? God forbid!

This glaring inconsistency in its position might well come back to haunt the Lääkäriliitto.

3) part of the objection is that medical procedures should not be part of religious ceremonies. That argument in itself is circular, as it automatically precludes circumcision regardless of any other considerations.

4) they are concerned that allowing the practice to be done under a medical jurisdiction implies the doctor has called for the procedure and the parents are merely consenting, and also, importantly, that the costs (and insurance I imagine) of the procedure are therefore borne by the health care system. Clearly this is not so much a question of ethics but of economics.

5) They suggest religious communities be persuaded to abandon the practice, but that in the meantime, a compromise may be to postpone the procedure until the boy is able to give consent. A difficulty with this though is that the older the boy, the more expensive the procedure and also the more necessary it will be for the procedure to be done within a health setting. Likewise, clearly compared to infants, young boys are much more likely to find the procedure distressing, both through anticipation and possible discomfort. Likewise, the psychological impact could be far greater if carried out under social pressure when the boy is in the 6-10 age range.

I do think that one argument that lääkäriliitto bring up has some merit to it. They call for further study into the social effects, particular negative, for men who have undergone the procedure. I think that if there is a debate to be had, and if religious communities were to develop some flexibility over this practice, then it will perhaps find its social justifications through the testimonies of the men affected by it. It is interesting that lääkäriliitto point out that by allowing the practice to be performed within medical settings will likely lead to further entrenchment of the practice. Indeed this is the case with secular circumcision in the US.

What also needs to be considered within the ethical debate, in addition to any strict or loose interpretation of medical ethics (and I don’t blame doctors for erring on the side of strictness, especially in this day and age of medical costs and medical insurance) is a fuller debate about the ethics of religious freedom, as and of itself in today’s society. Doctors, as justifiably respected ‘experts’, should not however by viewed as having a complete picture of the ethics involved. As JD rightly points out, a doctor seeks to diminish risks to health, while much of society seeks to experience risk for entertainment value alone. Issues of identity should not always be considered to be subsumed to medical ethics. It’s not about closing our ears to what doctors have to say, but rather, opening our ears to what the people affected by any such proposed change also have to say. At some point we have to balance the right of one portion of society to tell another portion of society how they should act.

What I absolutely object to in this debate is that it’s often championed by political activists on the Far Right who also happen to have, as if by accident, an anti-Muslim, and historically, an anti-Semitic agenda, both of which groups would most obviously be affected by any change in policy. An accident? Yeah, right….

We have to be extremely skeptical towards such manipulations of this debate. Indeed, if these parties or individuals are going to be consistent, then I suppose they will also oppose abortion on the same grounds. Let them come out and say exactly that in black and white, if it’s merely a matter of being consistent in our medical ethics and not part of their broader anti-multicultural agenda.

Note: this is reproduced in large part from a comment to an earlier post on this topic. Apologies if you have read both expecting a lot of new material. Likewise, if any parts of my portrayal of the Medical Association’s stance appear incorrect, I would appreciate being corrected.