Varie maggio 1997

GENERAL MEDICAL COUNCIL, (U.K.), London, England, May 1997.

GUIDANCE FOR DOCTORS WHO ARE ASKED TO CIRCUMCISE MALE CHILDREN

INTRODUCTION

Background

1. We decided to review the issues raised by male circumcision as a result of a number of complaints made to us. These concerned doctors who had not provided an acceptable standards of practice when performing the procedure. We had also received a number of letters questioning the ethics of the procedure and asking for our views on whether, and in what circumstances, the procedure was acceptable, for either religious or therapeutic reasons.

2. Circumcision raises difficult questions about the rights and freedoms of individuals. Many maintain that individuals have a right to practise their religion unhindered; while others feel it is unequivocally wrong to undertake a surgical procedure, with its attendant risks, on an infant who is unable to consent. These are not primarily medical matters and we do not think they can be resolved by the medical profession alone. They are matters for society as a whole to decide. Nonetheless, we have a responsibility to protect patients and guide doctors, and we have therefore undertaken to provide guidance which sets out the principles of good medical practice for those doctors who are asked to perform circumcisions for religious or for medical reasons.

3. In 1996 we invited views from religious organizations, anti-circumcision pressure groups, professional and patients’ organisations, and civil rights and children’s organisations on a preliminary draft of a guidance for doctors who are asked to perform male circumcision.

Consultation Exercises – summary of responses
Rights and Freedoms
4. Male circumcision is considered by many in the Jewish and Islamic faiths to be essential to the practice of their religion; they would regard any restriction or ban on male circumcision as an infringement of a fundamental human right. Some respondents argued that if doctors could not carry out the procedure, parents would turn in greater numbers to individuals who lacked the skills and the experience to perform it safely and competently.

5. Some replies, including many from civil rights and children’s representative organisations, acknowledged the difficulty in achieving a balance between the rights of the child and the rights of individuals to practise their religion. However, they strongly believed that, because circumcision for non-therapeutic reasons carries risks, it is wrong to perform the operation on children who were not old enough to give informed consent. This belief was shared by Norm UK, and others who campaign for a ban on male circumcision in the UK.

6. Many civil rights and children’s organisations referred to the UN Convention on the Rights of the Child (ratified by the UK Government in 1991). They placed most emphasis on Article 24.3 which states that ratifying states should `take all effective and appropriate measures with a view to abolishing traditional practices prejudicial to the health of children’. However, this should be balanced against Article 9.2 of the European Convention for the Protection of Human Rights, which protects the rights of individuals to practise their religion.

7. The Law Commission has undertaken a consultation exercise on consent in the criminal law (ending 31.1.97); a short section of the Law Commission’s report argues that male circumcision is lawful in the UK. One respondent told us that the Law Commission’s opinions on this point have been challenged. However, all this legislation is untested in the context of circumcision. The legal position therefore remains unclear.

Views about harm and benefit
8. Many replies suggest that the medical profession has a duty to provide the public with objective information about circumcision; and that doctors should be obliged to provide counseling to parents before, and after circumcising their child. Others thought that doctors should not put undue emphasis on the risks of the procedure, because there was insufficient evidence to justify worrying the parents about it. However, a considerable number of respondents held the view that because circumcision has very few medical benefits, and the potential dangers to the child outweighed these, circumcision is inappropriate under any circumstances. A number of these respondents, some of whom had been circumcised as infants and who as adults, believed they had been seriously damaged by the procedure, felt strongly that circumcision should be made unlawful.

9. Others who wrote to us offered constructive advice on the text of our guidance as well as commenting on the wider issues. Many expressed concern about the welfare of infants who are circumcised for religious or cultural reasons by people who do not have appropriate level of medical knowledge and skill. Some asked that guidance be introduced which obliged doctors to undertake the procedure in hygienic conditions, with appropriate pain relief and aftercare.

In conclusion
10. We are very grateful to everyone who took the time and trouble to send us their views. As shown above, many of the respondents held conflicting views. In drafting our guidance for doctors we have considered, as objectively as possible, all of the views and information put to us. Our aim is to provide guidance which will help doctors to provide a good standard of care for their patients.

11. Our published guidance does not specifically address the rights of children. However, many of the principles set forth in our booklet Good medical practice are of broad application and should be followed by doctors when they are asked to perform circumcisions. The guidance which follows is based on the principles in this booklet.

Standards of practice for doctors asked to circumcise male children
If you decide to circumcise a male child you must:

Have the necessary skills and experience both to perform the operation and to reduce the pain and discomfort of the patient
Keep up to date with developments in the practice of male circumcision including when the procedure is, and is not, necessary for medical reasons
Explain objectively to those with parental responsibility for the child any benefits or risks of the procedure, taking into account the age of the child
Explain to those with parental responsibility that they may invite their religious adviser to be present at the circumcision to give advice on how the procedure should be performed to meet the requirements of their faith
Listen to those with parental responsibility and give careful consideration to their views. You are not obliged to act on a request to circumcise a child, but you should explain if you are opposed to circumcision other than for therapeutic reasons. You should also tell those with parental responsibility that they have a right to see another doctor
Obtain the permission of both parents whenever possible, but in all cases obtain valid consent, in writing, from a person with parental responsibility before performing the procedure
Provide appropriate after care.