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Questions, questions…

25 Jan, 10 | by Iain Brassington

In response to the post below about circumcision, “IntactByDefault” asked a number of questions.  I think that they merit a thread of their own, although I’ve touched on some of the issues before.

Is it not the case that, short of legislation, the role of bioethicists is to put a check on the potentially unethical behaviors of those who practice medicine on humans?

Why have the rights of male children been subordinated to such issues as cultural habit and medically superfluous parental preference or belief?

Why aren’t bioethicists, including yourself, relentlessly shaming and using any other tool at your disposal to correct the behavior of medical practitioners who modify the genitals of children without meeting the ethical standards developed to protect the rights of minors?

For context, I suppose I ought to say why I made the post I did: it’s not because circumcision is something that interests me in particular, but I do know that it is an area of interest for some bioethicists and people in related fields, and the Freethinker article caught my eye.  More generally, I’m interested in it insofar as it’s something that’s always controversial, and I quite like watching the debates from the sidelines.

So: to IBD’s questions.  The second question is one for the anthropologists, and I’ll leave it unanswered.  In respect of the others, I think that he/ she/ it/ they are probably starting from the wrong premise, confusing the role of the bioethicist with that of the campaigner.  qua bioethicist, I don’t think that my (or our) role is really to campaign at all – it’s to analyse.  The point of this analysis is to get rid of misapprehensions and poor arguments, but the process is, I think, ideologically neutral; we go – or aspire to go – where the arguments take us.  That’s why we aren’t “relentlessly shaming” anyone: that’s not what we’re about.

Moreover, the questions take it as read that ritual circumcision is obviously indefensible, and I don’t accept that.  There’s a number of reasons why.  If it was as clear-cut an issue as that, noone would do it.  Indeed, I find it hard to make sense of the idea of a moral agent who acts for reasons other than those he thinks right, good, or justified – call this my justification thesis.  The fact that it does happen indicates that at least some people think that, whatever the reasons not to circumcise, there are also reasons to do so; they might accept that circumcision is bad in its own terms, but justified by some larger consideration.  Now, the argument to be had here is twofold: first, are they correct to identify a larger justification?  Second, have they located the pivot between the reasons for and the reasons against in the right place?  (And, I suppose, second-and-a-halfth, have those who take an opposite view identified the correct reasons in the correct place?)

For those bioethicists who are doing work on circumcision, these will be the major questions.  The most that anyone could say, I suspect, is that they hold ritual circumcision to be acceptable or unacceptable based on this evaluation of the reasons why it’s performed.  But – and this is worth repeating – even this strong line really has to take account of there being, at the very least, some reason to go through with the procedure.  mutatis mutandis, the same will apply to any other procedure as well.  When we say that someone is behaving in a morally problematic manner, we aren’t - I don’t think – saying that they’ve woken up and chosen the obviously wrong in preference to the obviously right; we’re saying that they’ve misidentified the right.

And, of course, it works the other way: when someone says that pis a clear violation of someone’s rights, can we be sure that those rights have been correctly identified?  Either way: the interesting moral questions are precisely those where matters are not as clear as they seem at first.  And, granted the justification thesis above, it strikes me that almost all situations will be ones in which much is unclear.

That’s why the question of “correcting” behaviour is a tricky one.  That’s why I think that IBD’s questions are, perhaps, starting from the wrong assumptions.  Indeed, rather too big an assumption about the moral clarity of the world seems to be what motivates the question.

Posted in Navel-gazing, Philosophy, Thinking Aloud.
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  • http://twitter.com/IntactByDefault IntactByDefault

    Iain, first let me clarify, I am a “he”, not a “she” or an “it”!

    Fair point regarding the distinction between bioethicist and campaigner, so let’s focus on the analysis.

    My question used the term “medical practitioners” because I was asking about the practice of medicine, and the ethics which govern it; not “ritual circumcision.”

    Perhaps my questions could have been better at getting to the heart of the matter. I’ll be more specific.

    Why should it be considered an ethical medical practice to accept proxy consent to non-therapeutically remove the male prepuce, unless the same is so for the female prepuce and other parts of the normal, healthy human body?

    I am positing an obvious double-standard which is applied exclusively to the male prepuce. Do you dispute that this double-standard exists? If so, can you state a coherent ethical system which permits parents to remove (for any reason, regardless of medical indication) the male prepuce, but not to remove other part of their child’s body?

    Clearly I am motivated by my own analysis of the ethics of non-therapeutic newborn circumcision, but that shouldn’t stand it the way of analyzing whether my arguments are sound, or where they fail.

  • Alex

    I don’t understand this post, at all. You say, “can we be sure that those rights have been correctly identified?”, but let me say this back to you: do you say the same thing about, say, murder? Because it is the same principle of rights that means murder should be illegal and that circumcision of young children should be illegal.

    You haven’t struck me as nihilist before, but this post certainly reads like you are one.

  • Ian Wilkinson

    Iain,

    Do you believe human beings have a moral right to self determination over their body parts? Given medical authorities such as the Royal Australasian College of Physicians has acknowledged the functional role of the foreskin and questioned the ethics of infant circumcision does that not make a case for non-therapeutic circumcision being an unethical medical procedure?

  • http://www.RestoringForeskin.org Restoring Tally

    I thought the fundamental principles of bioethicists included autonomy, beneficence, and justice. The removal of the prepuce during infant circumcision violates those principles.

    The patient has not given informed consent to have part of his genitals removed. With respect to autonomy, some may argue that parental choice governs, but what are the limits to parental choice for medical procedures? Can a parent choose to have the breast tissue of an infant removed to minimize the risk of future breast cancer? The risk of breast cancer is much greater than the risk of penile cancer. If anything, breast reduction surgery should be more acceptable. Is it? Or is it abhorrent because of cultural considerations?

    With respect to beneficence, there is no evidence of overwhelming medical benefit for non-therapeutic infant circumcision. The immediate health of the infant is not compromised if he is left intact. There are well known risks to the procedure. Is it ethical to perform non-therapeutic surgery on an infant? Or is it ethical to do so only if the surgery is male circumcision?

    With respect to justice, there are growing numbers of men who are unhappy with their circumcision. They are learning more about circumcision and they are able to identify how it harmed them. Can a bioethicist ignore that a growing number of patients, who never personally gave informed consent, would prefer not to have been circumcised?

    Unfortunately, you sidestepped the issues. I believe the rights of patients has been well established. The cultural norms in the US are contrary to some of those rights, such as the right to bodily integrity of male infants. Culturally, the US recognizes the right to bodily integrity of females. Is the disparity between male and female bodily integrity ethical? As a bioethicist, are you guided by local cultural norms or are you guided by the basic rights of patients that have already been identified?

  • http://www.law.manchester.ac.uk/aboutus/staff/iain_brassington/default.htm Iain Brassington

    Hmmmm… I’m not going to be able to do anything like justice to all these questions; still, I’ll have a go.

    Alex, first. I’m not sure about nihilist, but I’m certainly a sceptic (in the best sense of the word), and it’s certainly the case that I think that a lot of rights-talk is a dressed up form of “I-really-want-this” talk – which is clearly not the same thing. And I really don’t think that the wrongness of murder is comparable to the alleged wrongness of circumcision – not least because if a killing-action wasn’t wrong, it wouldn’t be murder. That is, the wrongness of murder strikes me as being analytic (or near as dammit), and the same doesn’t apply to circumcision.

    Ian – The subtext of the post was more along the lines that I think that, whatever the reasons not to circumcise, I have to assume that at least some people think that there are at least some reasons to do so. Those reasons merit consideration; the analysis of (competing) reasons is a big part of what ethics is about. Meanwhile, the fact that this or that body has raised questions about procedure p is neither necessary nor sufficient to show that there’s a case for p‘s wrongness.

    Restoring Tally – The replies above ground how I think I’d reply to you: I disagree that bioethics, or bioethicists, have those four “fundamental” principles. They aren’t fundamental; they aren’t universally accepted; and – for me at least – they’re a pretty poor guide to ethical decisionmaking. When it comes to a conflict between cultural norms and basic rights – well, like I said, I’m a bit suspicious of rights talk; but I’m also no cultural relativist either. So I’d say that neither is more important. I won’t bore you by filling the hole with my own ill-formed theoretical musings here.

    On the other hand, you do make a good point about equality of consideration for male and female children, and this would certainly inform any debate on the issue. (For what it’s worth, my hunch is that it’d be vital, and possibly a clincher – but that’s not what the OP was about.)

    IBD – I guess you could probably deduce my answer to much of your question from the above. I’d just add that though I couldn’t begin to give an account of the coherent ethical system that you think would be necessary to justify male circumcision, that doesn’t mean that I can’t accept that such a thing would be possible. And there are ethicists who’d have a crack at presenting and defending it.

  • Alex

    Iain, you say to Ian:

    “whatever the reasons not to circumcise, I have to assume that at least some people think that there are at least some reasons to do so”

    But again, this strikes me as nihilism. Yes, people who do things have reasons to do so. Some religious parents circumcise their children. The fact they do so, and think they are right to do so, proves nothing. Bad people do bad things (hell even generally good people do bad things from time). There’s a risk of sounding like a broken record, but the fact that murderers exist proves nothing about whether murder is a good or bad thing. Most people see it as a bad thing, and think those people who want to murder should be stopped from doing so. I’m not saying that circumcision of children and murder are morally equivalent, but they are both morally bad in my book, so why shouldn’t circumcision of defenseless children by stopped? The fact that there are people who want to circumcise is completely irrelevant and independent of whether or not it is morally wrong or not, and should be legally restricted or not. Yes, the reasons such people give “merit consideration”, but once considered, I see no reason to do anything but reject them. Why don’t you?

  • http://www.law.manchester.ac.uk/aboutus/staff/iain_brassington/default.htm Iain Brassington

    In what sense is this nihilistic?

    I’ve deliberately not entered into the debate about the rights and wrongs; I’ve commented only on the “metadebate” – about how that debate is framed.

    Also, I’m a bit puzzled by two of your statements: you say that people’s belief that circumcision is acceptable doesn’t make it so – which is, of course, true – but then say that “[circumcision and murder] are both morally bad in my book, so why shouldn’t circumcision of defenseless children by stopped?”, which seems to imply that your thinking something does make it so.

    If you genuinely can see no reason to circumcise, the implication is that you’re accusing circumcisers not just of irrationality, but of arationality. That doesn’t seem correct – and if it is correct, it seems to make moral argument pointless. by contrast, your final sentence suggests to me that you’ve decided a priori that there can be no reason sufficient to justify the practice. Maybe there is no such reason; maybe there could be none. But I think that the a priorism is still a bit dodgy; the objection has to be proved, and can’t just be assumed.

  • http://twitter.com/IntactByDefault IntactByDefault

    Instead of debating right and wrong, here’s the important metaframe. Are there logical inconsistencies in the right or wrong arguments which require rejecting them or challenging other positions held? If so, then we must do one or the other, or reject it.

    The medical ethics meta argument is that the same consideration must be applied to the amputation of any minor’s body parts. If its ethical for medics to remove body parts from minors on behalf of parents for any reason (culture, belief, etc.) then it must also be so for other body parts and to all minors (not just males).

    Right or wrong, there is no medically ethical justification for applying unique rules to a very narrow set of anatomical features, all residing only on males.

  • http://www.law.manchester.ac.uk/aboutus/staff/iain_brassington/default.htm Iain Brassington

    But noone is suggesting unique rules, I don’t think; it’s a matter of applying the same rules. For example, it seems perfectly possible to me for someone to say that male circumcision is bad, but that female circumcision is worse, and to give reasons for that.

    Now, you can take or leave that view. But the point would stand that too blithe an application of a given moral rule is unlikely to generate a morally sound set of conclusions.

  • http://twitter.com/IntactByDefault IntactByDefault

    Iain,

    Presently, in societies such as the UK and the USA, physicians are permitted to perform male circumcision (removing normal, healthy anatomy) on children based exclusively on parental preference (for any reason whatsoever).

    You also know that presently, in those societies, physicians are not generally to permitted to remove normal, healthy anatomy from children based exclusively on parental preference.

    For example, a physician cannot remove a child’s finger because the parents prefer it. A physician cannot remove a child’s eyelids because the parents prefer it.

    The rules for the anatomy removed by male circumcision are, presently, unique.

    Have I illustrated this point sufficiently for you to accept it, or do you dispute this point?

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