Autonomy and the Circumcision Wars

Guest Post by Akim McMath

In December of last year, the Centers for Disease Control and Prevention (CDC) released its proposed new recommendations on male circumcision.  The verdict?  Circumcision provides major benefits with minimal risks.  These benefits accrue whether circumcision is performed in infancy or later on in life.  Circumcision may even help to stem the HIV epidemic in the United States.  Perhaps you should do something about that foreskin.

The resulting firestorm was swift, fierce, and predictable.  Critics of infant circumcision blasted the CDC, accusing it of trampling the child’s right to bodily integrity.  Defenders of circumcision fired back, extolling the prophylactic virtues of the procedure.  Subtle questions about autonomy were lost in the maelstrom.  Yet these questions lie at the heart of the conflict, as I suggest in a new article.

Let’s look more closely at the debate over circumcision and HIV.  Defenders of circumcision tout studies showing that circumcision reduces female-to-male sexual transmission of HIV.  Critics retort that there exists a more effective and less drastic means of achieving the same end – namely, condoms.  Perhaps, concede the defenders, but many men don’t use condoms consistently and effectively – hence the enduring problem of STIs.  That’s their choice! say the critics.  So? say the defenders.  And so on, ad infinitum.

The foregoing squabble is essentially a disagreement about autonomy.  Critics of infant circumcision are idealists about the child’s future autonomous choices.  They assume that the child will make prudent choices in future, even when he may not.  Assuming prudent condom use, circumcision is unlikely to provide much additional protection against HIV.  Defenders of circumcision, on the other hand, are realists about the child’s future choices.  They account for the fact that the child may not make the best choices in future.  On more realistic assumptions about the child’s future condom use – or lack thereof – circumcision may provide significant additional protection.

So who is right: the realists or the idealists?  Is infant circumcision an acceptable precaution against harms that may result from irresponsible choices in future?  Or should we give the kid the benefit of the doubt and assume he will make prudent choices when he is older?

Consider the ethics of coercion more generally.  Typically, coercively protecting people from their own autonomous choices – or strong paternalism – is deeply problematic.  Respect for autonomy requires that we allow people to make foolish choices.  On the other hand, there is nothing paternalistic about coercively preventing people from harming others.  As some clever person once put it, “My right to swing my fist ends where your nose begins.”

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.  When we are just considering the child’s own interests, we should be idealists about his future autonomous choices.  To circumcise him now in order to protect him from imprudent choices in future would be strongly paternalistic, and would therefore be objectionable.  But there are other interests at stake.  Since HIV is an infectious disease, reducing one person’s risk of HIV infection reduces the risk to many others.  When we consider this wider public health perspective, we should be realists about the child’s future choices.  Public health policy should be based on the choices people actually make, not on the choices they might make in an ideal world.

What does all this mean for the CDC recommendations?  It suggests that the CDC relies far too heavily on HIV prevention as a justification for infant circumcision.  In the United States, the adult prevalence of HIV is 0.6 percent – not very high by global standards.  Furthermore, as the CDC itself admits, only 10 percent of new infections are transmitted sexually from a female to a male.  And, 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.  All of this suggests it would take very many (perhaps thousands) of circumcisions to prevent one new ethically relevant HIV infection in the United States.  The public health justification for infant circumcision, at least in terms of HIV prevention, seems much weaker than the CDC’s enthusiasm would suggest.

In any case, the circumcision wars will go on – and there is no end to the conflict in sight.

Read the full paper here.