Consent for circumcision
Online posting: Oct. 30, 1996
Published in print: Jan. 1, 1997 (CMAJ 1996;156:18)
In response to: R.S. Van Howe
Re: Bioethics for clinicians: 1. Consent, by Edward Etchells,
Gilbert Sharpe, Phil Walsh, John R. Williams and Peter A. Singer,
CMAJ 1996;155:177-80 [full text / résumé]
A neonate is incapable of providing consent. As we stated in
our article, incapacity is not an exception to the requirement
for consent, and substitute consent should be sought. If
circumcision were performed without substitute consent, this
would constitute battery.
In most cases, this substitute consent is provided by the
neonate's parents. Dr. Howe states that "parental permission is
only acceptable when the medical intervention is of clear and
immediate medical necessity." He cites the Committee on Bioethics
of the American Academy of Pediatrics, which also suggests that
"the pediatrician's responsibilities to his or her patient exist
independent of parental desires or proxy consent," and that
providers of care to neonates "have ethical and legal duties to
their child patients to render competent medical care based on
what the patient needs, not what someone else expresses."[1]
These statements suggest that the authority to provide
substitute consent for a neonate lies with the clinician rather
than the parents. However, this view is inconsistent with
existing Canadian legal, ethical and professional standards. The
authority to provide substitute consent lies with the parents.
Some limits to parental authority have been established though
law or professional policy. For example, the Supreme Court of
Canada has ruled that parents may not subject their children to
nontherapeutic sterilization,[2] and the College of Physicians
and Surgeons of Ontario, in its policy on female circumcision,
excision and infibulation, states that "the performance of any of
these procedures by a physician who is licensed in Ontario will
be regarded as professional misconduct."[3] However, there are no
established limits to parental authority in regard to consent to
male circumcision. The Fetus and Newborn Committee of the
Canadian Pediatric Society has recommended that circumcision of
male newborns not be routine, but that the decision be made based
on the social, rather than the medical concerns, of the
parents.[4]
Dr. Howe cites a study that showed that parents were unaware
of all of the risks and benefits of circumcision. The same study
found that most parents did not want to be informed of all of the
risks and benefits: "mothers in the current study frequently did
not desire a comprehensive disclosure of the medical
complications, and often seemed to resent the physician for
presenting it to them. In this case, a desire to have a partial
disclosure of the medical complications may be a result of the
social, traditional, or religious considerations that motivate
the request for [circumcision]."[5] On the basis of these
observations, it is difficult to conclude that failure to
disclose all known risks is actually negligent.
We suggest that clinicians provide parents with adequate
information about the risks, benefits and alternatives that a
reasonable person in the parents' position would need to know to
make a decision. A nonjudgemental inquiry into the parents'
reasons for the circumcision may be a useful step in disclosure.
If the parents' decision is based on strong cultural beliefs and
practices, a detailed, impersonal disclosure of all known risks
and benefits would probably not be relevant or helpful. However,
if the decision is based on personal experiences (e.g., the
father was circumcised), a detailed discussion of the risks and
benefits may be useful in helping the parents to come to a
decision.
Edward Etchells, MD, MSc, FRCPC
University of Toronto Joint Centre for Bioethics
Department of Medicine
Toronto Hospital
Toronto, Ont.
eetchells@torhosp.t
oronto.on.ca
Gilbert Sharpe, BA, LLB, LLM
Professor
Faculty of Health Sciences
McMaster University
Hamilton, Ont.
Director
Legal Services Branch
Ontario Ministry of Health
Toronto, Ont.
Phil Walsh, BSc, LLB
Student-at-law
Legal Services Branch
Ontario Ministry of Health
Toronto, Ont.
References
- American Academy of Pediatrics Committee on Bioethics.
Informed consent, parental permission, and assent in pediatric
practice. Pediatrics 1995;95(5 pt 1):314-7.
- Re Eve, [1986] 2 SCR 388
- Female circumcision, excision, and infibulation.
Toronto: College of Physicians and Surgeons of Ontario. 1992.
College notices, 1992, issue number 25.
- Fetus and Newborn Committee, Canadian Pediatrics Society.
Neonatal circumcision revisited. CMAJ
1996;154:769-80.
- Christensen-Szalanski JJ, Boyce WT, Harrell H, Gardner MM.
Circumcision and informed consent. Is more information always
better? Med Care 1987;25:856-67.
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