THE HEALTH QUESTION

One thing is very clear: if you opt for the procedure depicted in the video, then you should also insist on the pain relief. It boggles the mind to suppose that the procedure could be anything but excruciating, if performed without the lidocaine injections. Granted, it was once thought that babies were incapable of feeling any pain, but that view is obsolete; and the sorts of procedures in question are generally assumed to cause pain. The American Academy of Pediatrics states that the newborn’s age is not a reason to withhold anesthesia; newborns are not insensitive to pain or oversensitive to anesthesia. In fact, about 45 percent of circumcisers do use some form of anesthesia—far more pediatricians do than obstetricians—and of those, 85 percent use lidocaine injections. 55 percent of circumcisers don’t provide any anaesthesia at all.

But should circumcision be done at all, for strictly health-based reasons? The medical benefits of circumcision are somewhat controversial. Circumcision is correlated with a reduction in penile cancer; however, penile cancer is rare, both in circumcised and non- circumcised men. Also, penile cancer is closely connected to the HPV virus, and there is now a vaccine that protects against some of the varieties of the virus most closely linked to penile cancer (and cancers in women). Condoms also help prevent HPV infection. Another well-established health benefit of circumcision is a reduction in the rate of urinary tract infections. That’s good, of course, but UTIs are easily treated with antibiotics.

Circumcision is also correlated with a significant reduction (5060 percent) in the risk of acquiring HIV-AIDS for heterosexual men living in high-prevalence regions such as South Africa, Kenya, and Uganda. High-quality studies have shown that this reduction really is due to circumcision, and not to concomitant factors. This should be a powerful consideration for parents who live in such places. However, it’s not so clear to what extent circumcision will protect against HIV if you and your son live elsewhere. In the West, HIV-AIDS is far less prevalent and men who have sex with men are the subpopulation most affected. Circumcision has not been shown to reduce HIV risk in that group. With respect to heterosexual transmission in the United States, there has been very little research on the efficacy of circumcision. Extrapolation from the African studies may or many not be warranted, because there are many differences between populations with potential relevance: for example, there are differences in condom use, whether for cultural, educational, or economic reasons. Since condoms are extremely effective in preventing HIV infection, we would not expect circumcision to make the same difference in places where condoms are used at very different rates (the United States and Europe are at the high end, and some of the African countries most affected by the AIDS epidemic are at the low end, according to the United Nations). And bear in mind that public health experts do advise African men to use condoms after circumcision to prevent HIV infection or transmission. Of course, condoms are also valuable for preventing other sexually transmitted diseases as well as pregnancy. All that being said, it’s reasonable to think that there is some HIV prevention associated with circumcision, wherever you live. And we should bear in mind that some of the benefit goes beyond men—women are less likely to be infected with HIV when fewer men have it, and thus also less likely to pass it on to babies during pregnancy.

Putting all three health benefits together, along with others, the aggregate is at least some reason to circumcise. But then there are costs, as well. Foreskins function in a way that’s pleasing to those who have them (though rarely missed by those who lack them). The circumcised boy loses that functionality. He also runs risks from having the procedure. Though very rare, there are periodically deaths and injuries as a result of circumcision. The costs narrowly related to the procedure are pain during the procedure, especially if anesthesia isn’t used (which simply seems inexcusable); and pain during the recovery period.

So where does that leave us? In 2012, the American Academy of Pediatrics (AAP) announced its new position on circumcision: that the health benefits of the procedure (for American newborns) outweigh the risks, but nevertheless are not great enough to justify recommending routine circumcision for all male newborns in the United States. On the other hand, they advise that insurance companies should cover the procedure. By contrast, in the United Kingdom, the National Health Service doesn’t recommend circumcision and doesn’t pay for it. Likewise, the Canadian national health service doesn’t pay for routine circumcision. And even in the United States, Medicaid doesn’t cover the procedure in eighteen states (as of 2016).

The AAP policy statement states that parents should decide "whether circumcision is in the best interests of the male child,” but it also says this: parents "will need to weigh medical information in the context of their own religious, ethical, and cultural beliefs and practices.” Putting ethics in a separate "context” list might make it seem as if health considerations don’t involve ethics, but that’s not so. It’s an ethical matter how we should use the facts about health costs and benefits to arrive at a conclusion about what is medically warranted and what isn’t.

One thing we must do, to make an ethical assessment of the health question, is to focus on health ethics rather than conformity or religion. I see no way to avoid these distractions except through the help of a thought experiment. So please imagine this: a world in which boys are born both with and without foreskins, like they are actually born with different skin colors or eye colors. Nobody stands out for having a foreskin or lacking a foreskin in Mixed World. Men don’t care if they are foreskin matched with their sons any more than they care if they are eye-color matched with their sons. The average man would have seen both kinds of penises and the average heterosexual woman would have had partners with both kinds. There is no practice of routine circumcision, like in the real world we have no practice of routine infant tattooing, scarification, or ear-lobe removal.

Now imagine that you are going to have a baby boy in Mixed World, and then this happens: scientists start studying the two groups and decide there are certain health benefits to having no foreskin. The costs and benefits are exactly what they are in the real world, but there are no conformity or religion factors. What will you do? What should you do?

One possibility is to do just as the cost-benefit analysis suggests. If benefits are even slightly higher than costs, then we should have the procedure done. I think this would be the right approach if we were thinking about any number of other medical issues. Should the obstetrician put antibiotic drops in your baby’s eyes right after birth? If the benefits exceed the costs, then yes. Should the pediatrician draw blood to check your baby for some possible problem? If the benefits exceed the costs, then yes. However, circumcision differs from drawing blood or giving eye drops. Unlike these procedures, it’s the permanent, body-altering removal of a healthy, functional body part. Unlike other parts, such as blood, or the stump of the umbilical cord, the foreskin would be a permanent part, if it weren’t for the procedure—a part on the outside, experienced as part of one’s personal “surface.” And the foreskin is a perfectly normal part, unlike a diseased appendix. Because circumcision is body-altering in this distinctive way, it seems proper to hold removing it to a higher standard than any of these other procedures—giving eye drops, drawing blood, and so on. We need more than benefits exceeding costs, we need ... what? The higher standard might be that benefits exceed costs by a wide margin. Or that they exceed costs by a margin that’s impressive to all thoughtful, educated people, so we’ve essentially reached consensus that the procedure is worthwhile. Or the higher standard might be that we can say for sure what our son would want us to do.

To my mind, these higher standards are not met, and I suspect that if we were in Mixed World, most parents would see that they are not met. It’s odd to perform surgery on a newborn baby instead of leaving him whole. It’s odd to make the judgment on a baby’s first day of life that a healthy, normal part of him is dispensable—that nature made a mistake. When health considerations alone are our guide, we do surgery on newborns only for the most compelling of reasons, and the health reasons in support of circumcision don’t seem to rise to that level.

 
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