Consent and circumcision

Our genitals are a part of our bodies about which we often have intense feelings. We describe them using many different words. Some of these may be considered offensive and can evoke strong emotional responses, whilst others have evolved for use in polite conversation. One of these is the phrase “Private Parts”.
A child’s private parts are considered more vulnerable and more precious than those of an adult. Society usually provides a very high degree of protection to children’s genitals from adult interference; however society waives that protection and accommodates adult demands that non-therapeutic genital surgery is performed on healthy children. Such surgery is known by various names including “Gender Assignment” for intersex children and “Circumcision” in males and females. By allowing these demands from adults to go unchallenged, we deny children the protection they deserve.

Freedom of choice
The freedom to make our own decisions is also something about which we have strong feelings. When it comes to our own bodies, many of us consider the freedom to make decisions for ourselves to be a fundamental right. Philosopher John Stuart Mill in his book “On Liberty” expressed freedom of choice in this way: “Over himself, over his own body and mind, the individual is sovereign.”
The decisions we have to make in order to exercise our freedom of choice require us to have good quality information and the maturity and ability to process that information and come to an informed decision. Mill’s definition of freedom of choice has helped to develop the concept of informed consent, which has become a cornerstone of modern medical practice and the application of the law.

Any exceptions?
Medicine requires us to make some allowances; a surgeon could justify amputating a patient’s leg without their consent in certain circumstances – for example if the leg had been badly crushed in an accident and if the patient was unconscious and amputation was the only way to save him or her from death. This could be seen as an example of presumed consent, in that the doctor can presume that the patient would rather survive without a leg than die. However, in all cases where the patient is able, or will be able to understand, the doctor is required to provide suitable information and allow the decision to be made by him or her. This is particularly applicable where the patient is undergoing unnecessary surgery, for example cosmetic surgery.

Children
As children are not considered able to understand the information required to give informed consent they are treated as being in a similar situation to an unconscious patient. The surgeon must act if the child’s health is under immediate threat from disease or injury, but a healthy child deserves the same degree of protection from unnecessary surgery that would be accorded to any other patient unable to give informed consent. How do doctors justify removing healthy genital tissue from non-consenting children?

Medical ethics
The General Medical Council, the doctors’ regulatory body (G.M.C.) has a bizarre take on consent in relation to circumcision. Right at the top of the guidelines, where it should be is the following:

1. In our core guidance, Good Medical Practice, we advise doctors that: You must make the care of your patient your first concern.

The above echoes the doctors’ oath to “do no harm”.  The policy sounds as though it should protect anyone from being operated on when they have no disease or injury and have not requested or consented to the procedure. Sadly further on in section fourteen there is this piece of advice:

14. If you are asked to circumcise a male child, you must proceed on the basis of the child’s best interests and with consent. An assessment of best interests will include the child and/or his parents’ cultural, religious or other beliefs and values. You should get the child’s consent if he is competent. If he is not, you should get consent from both parents if possible, but otherwise from at least one person with parental responsibility.

The first sentence of section fourteen sounds as though it offers a child protection – no consent means no surgery. Whatever “assessment” the G.M.C. may make about the child’s “best interests” it cannot be proper to circumcise a child on the basis of his parents’ beliefs and values as they are not necessarily the beliefs that the child may hold in the future. This not a situation in which presumed consent could apply as the child is not under any immediate threat from disease and has no injury. Lastly how can it be right to accept the consent of two parents as valid consent? Neither parent is the patient, the patient has no disease or injury and therefore they have no right to consent to and the doctor has no justification for carrying out a medically unnecessary procedure. Doctors must remember that the child is their patient, not the parents and also remember their oath to do no harm.

The British Medical Association (B.M.A) holds a similar position to that of the G.M.C. Although the B.M.A. goes so far as to acknowledge, in their guidelines, that there is a downside to circumcising children.

In the past, circumcision of boys has been considered to be either medically or socially beneficial or, at least, neutral. The general perception has been that no significant harm was caused to the child and therefore with appropriate consent it could be carried out. The medical benefits previously claimed, however, have not been convincingly proven, and it is now widely accepted, including by the B.M.A, that this surgical procedure has medical and psychological risks. It is essential that doctors perform male circumcision only where this is demonstrably in the best interests of the child. The responsibility to demonstrate that non-therapeutic circumcision is in a particular child’s best interests falls to his parents.

The last two sentences are where the profession washes its hands of responsibility, if the parents convince the doctor that they will get the child circumcised elsewhere the doctor can say it is in the child’s best interests for him or her to do the circumcision and so limit the potential damage. The way to limit the harm to a child known to be at risk from abuse however is to inform the child care agencies and if necessary, get the child put on the child protection register so that the authorities can protect the child with court injunctions or other methods. It is not for members of the medical profession to collude with parents in an act that the profession itself says “has medical and psychological risks“. Surely exposing a healthy child to unnecessary medical and psychological risk can only be considered an abuse.

Everywhere you look in the National Health Service the emphasis is on freedom of choice, the right to choose your consultant, the right to choose your hospital; but if you are a young boy few in the medical profession will uphold your right to freedom of choice by protecting you from being subjected to unnecessary non-consensual genital surgery. If children were left intact until they could make an informed choice this sorry practice of cutting children’s genitals would probably come to an end as within a generation there would be no more mutilated parents pressurising doctors to violate children’s rights.