{"id":2882,"date":"2015-02-27T11:06:12","date_gmt":"2015-02-27T10:06:12","guid":{"rendered":"http:\/\/stg-blogs.bmj.com\/medical-ethics\/?p=2882"},"modified":"2015-03-01T11:28:04","modified_gmt":"2015-03-01T10:28:04","slug":"autonomy-and-the-circumcision-wars","status":"publish","type":"post","link":"https:\/\/stg-blogs.bmj.com\/medical-ethics\/2015\/02\/27\/autonomy-and-the-circumcision-wars\/","title":{"rendered":"Autonomy and the Circumcision Wars"},"content":{"rendered":"

Guest Post by\u00a0Akim McMath<\/i><\/strong><\/p>\n

\n

In December of last year, the Centers for Disease Control and Prevention (CDC) released its proposed new recommendations on male circumcision<\/a><\/span>. \u00a0The verdict? \u00a0Circumcision provides major benefits with minimal risks. \u00a0These benefits accrue whether circumcision is performed in infancy or later on in life. \u00a0Circumcision may even help to stem the HIV epidemic in the United States. \u00a0Perhaps you should do something about that foreskin.<\/p>\n

The resulting firestorm was swift, fierce, and predictable. \u00a0Critics of infant circumcision blasted the CDC<\/a><\/span>, accusing it of trampling the child’s right to bodily integrity. \u00a0Defenders of circumcision fired back<\/a><\/span>, extolling the prophylactic virtues of the procedure. \u00a0Subtle questions about autonomy were lost in the maelstrom. \u00a0Yet these questions lie at the heart of the conflict, as I suggest in a new article<\/a><\/span>.<\/p>\n

Let’s look more closely at the debate over circumcision and HIV. \u00a0Defenders of circumcision tout studies<\/a><\/span> showing that circumcision reduces female-to-male sexual transmission of HIV. \u00a0Critics retort that there exists a more effective and less drastic means of achieving the same end \u2013 namely, condoms<\/a><\/span>. \u00a0Perhaps, concede the defenders, but many men don’t use condoms consistently and effectively \u2013 hence the enduring problem of STIs. \u00a0That’s their choice! say the critics. \u00a0So? say the defenders. \u00a0And so on, ad infinitum<\/em>.<\/p>\n

The foregoing squabble is essentially a disagreement about autonomy. \u00a0Critics of infant circumcision are idealists <\/em>about the child’s future autonomous choices. \u00a0They assume that the child will make prudent choices in future, even when he may not. \u00a0Assuming prudent condom use, circumcision is unlikely to provide much additional protection against HIV. \u00a0Defenders of circumcision, on the other hand, are realists<\/em> about the child’s future choices. \u00a0They account for the fact that the child may not make the best choices in future. \u00a0On more realistic assumptions about the child’s future condom use \u2013 or lack thereof \u2013 circumcision may provide significant additional protection.<\/p>\n

So who is\u00a0right: the realists or the idealists? \u00a0Is infant circumcision an acceptable precaution against harms that may result from irresponsible choices in future? \u00a0Or should we give the kid the benefit of the doubt and assume he will make prudent choices when he is older?<\/p>\n

Consider the ethics of coercion more generally. \u00a0Typically, coercively protecting people from their own autonomous choices \u2013 or strong paternalism \u2013 is deeply problematic. \u00a0Respect for autonomy requires that we allow people to make foolish choices. \u00a0On the other hand, there is nothing paternalistic about coercively preventing people from harming others<\/em>. \u00a0As some clever person<\/a><\/span> once put it, \u201cMy right to swing my fist ends where your nose begins.\u201d<\/p>\n

We can look at the ethics of circumcision from two angles: from the perspective of the child’s own interests, and from a wider public health perspective. \u00a0When we are just considering the child’s own interests, we should be idealists about his future autonomous choices. \u00a0To circumcise him now in order to protect him from imprudent choices in future would be strongly paternalistic, and would therefore be objectionable. \u00a0But there are other interests at stake. \u00a0Since HIV is an infectious disease, reducing one person\u2019s risk of HIV infection reduces the risk to many others. \u00a0When we consider this wider public health perspective, we should be realists about the child’s future choices. \u00a0Public health policy should be based on the choices people actually make, not on the choices they might make in an ideal world.<\/p>\n

What does all this mean for the CDC recommendations? \u00a0It suggests that the CDC relies far too heavily on HIV prevention as a justification for infant circumcision. \u00a0In the United States, the adult prevalence of HIV is 0.6 percent \u2013 not very high by global standards<\/a><\/span>. \u00a0Furthermore, as the CDC itself admits, only 10 percent of new infections are transmitted sexually from a female to a male. \u00a0And, as I have argued, most of these initial infections cannot justify infant circumcision; it is the extent to which these infections increase risks to others that is ethically relevant. \u00a0All of this suggests it would take very many (perhaps thousands) of circumcisions to prevent one new ethically relevant HIV infection in the United States. \u00a0The public health justification for infant circumcision, at least in terms of HIV prevention, seems much weaker than the CDC’s enthusiasm would suggest.<\/p>\n

In any case, the circumcision wars will go on \u2013 and there is no end to the conflict in sight.<\/p>\n

Read the full paper <\/em>here<\/em><\/a><\/span>.<\/em><\/p>\n<\/div>\n

<\/p>\n","protected":false},"excerpt":{"rendered":"

Guest Post by\u00a0Akim McMath In December of last year, the Centers for Disease Control and Prevention (CDC) released its proposed new recommendations on male circumcision. \u00a0The verdict? \u00a0Circumcision provides major benefits with minimal risks. \u00a0These benefits accrue whether circumcision is performed in infancy or later on in life. \u00a0Circumcision may even help to stem the […]<\/p>\n

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