Circumcision: A Bioethical Challenge

  • J. Steven Svoboda, Executive Director, Attorneys for the Rights of the Child
  • Robert S. Van Howe, M.D., M.S.

"Professor Morris is a man on a mission to rid the world of the male foreskin."

-- Dr. Basil Donovan, Clinical Professor in the School of Public Health and Community Medicine, University of Sydney, reviewing "In Favour of Circumcision" by Brian Morris.[1]

"I have some good friends who are obstetricians outside the military, and they look at a foreskin and almost see a $125 price tag on it. Each one is that much money. Heck, if you do 10 a week, that's over $1,000 a week, and they don't take that much time."

-- Dr. Thomas Wiswell, co-author with Brian Morris of the latest defense of the AAP's proposal for government funding of circumcision.[2]

Infant male circumcision is one of the most divisive issues in contemporary society. When the American Academy of Pediatrics (AAP) issued its policy statement on circumcision in August 2012, it was met with international criticism for its cultural bias and lack of academic rigor. [3,4]. The AAP's response was disappointing. Rather than engage in debate, the AAP reacted defensively and simply reiterated its position.[5,6] In response to our own critique of the AAP[3], Professor Brian Morris--along with his familiar team of co-authors, including Dr. Thomas Wiswell (quoted above)[7]--takes the opportunity to rehearse his longstanding conviction that circumcision is a "biomedical imperative" for the 21st century.[8] The paper is nearly identical in content to a number of similar reviews and op eds by Morris et al. [Morris REFS: 21, 24, 46, 47, 52 , 55, 78, 79, 82], offering the same anthology of misleading claims and self-citations. We here call attention to a few of the most conspicuous.

Firstly, their description of the AAP as "a major, possibly the most pre-eminent, paediatric authority internationally" (p. 1, emphasis in original) is an example of a well-known rhetological fallacy, the appeal to authority. What is breathtaking about this particular example is that Professor Morris has criticised others for committing the very same fallacy--but only when such paediatric bodies failed to be as enthusiastic about circumcision as he is[i]. As Morris writes on his personal pro- circumcision website: "The policy statements of professional pediatric bodies have been misused by others as part of an 'appeal to authority' fallacy... Those who write the policy statements are often physicians with little or no academic expertise."[9] Thus, medical organizations which issue statements that are comparatively friendly toward circumcision (see footnote 1) are "pre-eminent" in Morris' view; whereas when their statements are less friendly, they are the work of mere "physicians" with "little or no academic training." As Morris then goes on to say, "Not surprisingly, [these statements] have been criticized by academic experts."[9] Note that Morris is using the term "academic experts" here as a covert , third-personal reference to himself, in conjunction primarily with his regular collaborators and other well-known circumcision promoters. This is a theme to which we will return.

At numerous points in his reply to our critique, Morris cites his own and his co-authors' opinions and seeks to pass them off as orthodox medical fact . This appears to be part of a larger strategy employed by Morris to distort the body of research on infant circumcision. As has been noted by others,[10] Morris scans the literature for any new published study that does not conform to his pro-circumcision stance, and then writes an article, letter, or blog post attacking it, enabling him later to claim that it was "refuted by experts" (i.e., by himself and his co-authors). One example of this is an attack on the statistical methods used by Sorrells et al. in a study showing that circumcision reduces sensitivity of the penis [Morris REF: 12]. The "numerous flaws exposed by experts" (p. 2) in this study were "exposed" by none other than Brian Morris himself, along with Mr. Jake Waskett--a 34-year-old "computer software engineer" and "web designer"[11] with no known academic expertise[ii]--in the form of a non-peer-reviewed letter exhibiting a manifest lack of statistical competence[iii]. This same self-citation tactic was employed multiple other times in his critique of our article [Morris REFS: 10, 12, 14, 62, 75, 76, 77, 91] and has been documented by other scholars subjected to the same abuse[iv]:

[As] in critical letters to the editor following other recent studies that failed to support their agenda, Morris et al. air a series of harsh criticisms against our study. As seen, however, the points raised are not well founded. It seems that the main purpose, as with prior letters, is to be able in future writings to refer to our study as an "outlier study" or one that has been "debunked", "rejected by credible researchers" or "shown wrong in subsequent proper statistical analysis." ... As these critics repeatedly refer to Morris' pro-circumcision manifesto as their source of knowledge, their objectivity must be questioned.[10]

Morris et al. are to be congratulated, of course, for their sheer energy in producing these unwarranted attacks. In doing so, they have managed to generate a sizable pro-circumcision canon, ready to be cited by like-minded writers whenever needed [Morris REFS: 24, 46, 47, 52, 55, 58, 65, 78, 79, 82, 102]. In the current critique, no fewer than 31 of the references are to other publications by Morris or his co-authors. Unfortunately, well-meaning peer-reviewers do not have the time to go down a "rabbit hole" of self-citations in order to properly evaluate each claim for its veracity.

Morris points to a "policy statement" by the Circumcision Foundation of Australia (CFA), implying that it operates with the approval of the Royal Australasian College of Physicians (RACP) (p. 1). However, nothing could be further from the truth. Morris fails to disclose[v] that he himself established the CFA[vi] (as well as drafted its "policy statement") in opposition to the RACP, which released a statement in October 2010 that failed to endorse routine circumcision[vii].[14] So misleading were Morris's claims that the RACP felt obliged to distance itself from him when he insinuated that he had been engaged as a reviewer for their College.[15] In a letter to Australian newspapers, Dr. David Forbes, Chair of the RACP Paediatrics & Child Health Policy & Advocacy Committee, stated: "Professor Morris ... is not a member of the RACP and is not and has not been engaged as a reviewer for the College."[16] As the CFA website now admits: "The Foundation is not aligned with any medical body."[13]

While Morris seeks, in this reply, to defend the AAP against its critics, even the AAP does not endorse the extreme conclusions that he and his co- authors draw (see footnote 1 for further discussion). As Morris has publicly insisted, circumcision "should be made compulsory ... [and] any parents not wanting their child circumcised really need a good talking to."[17] Morris's striking lack of objectivity concerning infant circumcision was noted by a leading sexual health researcher in a review of Morris's trade book, "In Favour of Circumcision"[18]: "Even the most naive reader can see that [the book] is very unbalanced. ... He preys on parental fears with his (unreferenced) claims. [Such claims are] so dangerous that it provides sufficient grounds for the publishers to withdraw the book."[1] As noted above, this same lack of objectivity is apparent throughout his reply to our critique.

Medical issues aside, however, the real challenge is to establish the ethical propriety of advocating, without qualification, the needless removal of healthy and functional body parts from non-consenting children. While the AAP at least recognizes the relevance of this basic bioethical issue (but fails adequately to address it, along with the actual anatomy and function of the tissue being removed)[3], Morris and colleagues offer arguments that are quite a bit more extreme. They float the idea that circumcision is less risky if performed in infancy, and then cite an opinion piece as supportive evidence.[Morris REF: 4][viii] They then repeat Morris' discredited analogy between circumcision and vaccination,[24] ignoring the fact that vaccination does not remove functional tissue, and is both the safest and most effective means of achieving the desired health outcomes--neither of which can be said of male circumcision. And they dismiss autonomy, the concept that is the very basis of modern bioethics,[25] as "radical."

In the final analysis, Professor Morris' exhortations ring of the same Victorian paternalism that held sway long before modern child protection measures or foundational concepts in medical ethics had ever so much as been proposed: "So great are the evils resulting not only from congenital phimosis, but from an abnormally long, though not phimotic, prepuce," wrote Erichsen in the late 1800s, "that it is only humane and right from a moral point of view, to practise early circumcision in all such cases."[26]

Modern doctors know better--or at least they should.

End Notes

i. Note that while the AAP cannot actually bring itself to recommend anything even approaching Professor Morris' stated ideal (i.e., "imperative" universal circumcision) it appears that Professor Morris has recognized that their recent policy statement is about as close as any respectable pediatric authority is ever going to get--hence, it would seem, his obsequious defense of them against our critique.

ii. Waskett does, however, have a long history of pro-circumcision activism, see Frisch[10]. Waskett has personally edited the Wikipedia pages on circumcision several thousands of times to reflect a pro- circumcision bias[11], leading it to become the 6th most "controversial" Wikipedia page (as measured by edits, re-edits, and re-re-edits) of all time.[12]

iii. In this and other "critiques," rather than provide reasoned arguments, the authors typically reject well-established and conventional statistical methods. Their ostensible lack of understanding of meta- regression [Morris REF: 91], mixed-marginal models [Morris REF: 22], representative cross-sectional survey sampling methods [Morris REF: 14], and attributable risk [Morris REF: 62], does little to boost the reader's confidence in their assessment of others' work.

iv. Morris does not limit himself to the tactics of letter-writing and passively-phrased self-reference. Instead, as was recently documented in the International Journal of Epidemiology, Morris also disregards the norm of confidentiality in peer-review, exhorting journal editors to reject well-conducted studies if they suggest that circumcision may be harmful. Responding to one such episode, a Danish sexual health researcher reported that Morris had been a "particularly discourteous and bullying reviewer who went to extremes to prevent our study from being published. In an email, Morris ... called people on his mailing list to arms against our study, openly admitting that he was the reviewer and that he had tried to get the paper rejected. ... Breaking unwritten confidentiality and courtesy rules of the peer-review process, Morris distributed his slandering criticism of our study to people working for the same cause."[10]

v. Morris not only routinely fails to acknowledge his affiliation with the CFA; he also outright denies it, violating conflict of interest disclosure rules. For example, in an article discussing the CFA on a popular Australian news site, Morris explicitly states: "The authors do not work for, consult to, own shares in or receive funding from any company or organisation that would benefit from this article. They also have no relevant affiliations " (emphasis added). See: http://theconversation.com/male-circumcision-policy-ignores-research-sho...

vi. Some of whose members, such as C. Terry Russell and Anthony Dilley, have incomes that come primarily or substantially from performing circumcisions: see http://www.russellmedical.com.au/; http://dranthonydilley.ypsitesmart.com.au/.

vii. The RACP statement reads: "After reviewing the currently available evidence, the RACP believes that the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand."[13]

viii. Citing an opinion piece in the AAP newsletter [Morris REF: 4] (which itself includes no references for its assertions) Morris et al. suggest that circumcision is "riskier" if left to adulthood. Complications may certainly be better documented for adults, who have the knowledge and wherewithal to complain if something goes wrong[19]; but there is no consistent evidence that properly-performed adult circumcision is actually riskier. It is true that it can be more costly, but only if proper pain control is used: general anaesthesia is contra-indicated in infants, meaning that the surgery is performed either with no pain control or with sub-optimal pain control, driving down costs at the expense of humane treatment. Only three studies have directly compared the complication rates of infant and later circumcision. One found no difference;[20] another found a significantly greater rate following infant circumcision;[21] and a third found the opposite when using a Plastibell device.[22] See also Ungar-Sargon[23] for further discussion.

References

1 Donovan B. Book reviews: In favour of circumcision. Venereology 1999;12(2):68-9.

2 Lehman BA. The age-old question of circumcision. Boston Globe, 22 June 1987; 43.

3 Svoboda JS, Van Howe RS. Out of step: fatal flaws in the latest AAP policy report on neonatal circumcision. J Med Ethics 2013;39:434-41.

4 Frisch M, Aigrain Y, Barauskas Y, et al. Cultural bias in the AAP's technical report and policy statement on male circumcision. Pediatrics 2013;131:796-800.

5 The AAP Task Force on Circumcision 2012. The AAP Task Force on Neonatal Circumcision: a call for respectful dialogue. J Med Ethics 2013;39:442-3.

6 Task Force on Circumcision. Cultural bias and circumcision: the AAP Task Force on Circumcision responds. Pediatrics 2013; 131: 801-4.

7 Morris BJ, Tobian AAR, Hankins CA, et al. Veracity and rhetoric in paediatric medicine: a critique of Svoboda and Van Howe's response to the AAP policy on infant male circumcision. J Med Ethics 2013; epub ahead of print.

8 Morris B. Why circumcision is a biomedical imperative for the 21(st) century. Bioessays 2007;29:1147-58.

9 http://www.circinfo.net/the_circumcision-debate.html

10 Frisch M. Author's Response to: Does sexual function survey in Denmark offer any support for male circumcision having an adverse effect? Int J Epidemiol 2011;41:312-4.

11 User: Jakew. http://en.wikipedia.org/wiki/User:Jakew

12 Yasseri T, Spoerri A, Graham M, Kert?sz J. The most controversial topics in Wikipedia: A multilingual and geographical analysis. In: Fichman P, Hara N, editors, Global Wikipedia: International and cross-cultural issues in online collaboration. Scarecrow Press, 2014. Available at: http://arxiv.org/vc/arxiv/papers/1305/1305.5566v1.pdf.

13 Royal Australasian College of Physicians, Paediatrics & Child Health Division. Circumcision of infant males. [cited 2010 Sep 29]. Available from URL: http://www.racp.edu.au/page/policy-and- advocacy/paediatrics-andchild-health

14 Circumcision Foundation of Australia website: http://www.circumcisionaustralia.org/

15 Hall L. Doctors circumspect on circumcision. Brisbane Times, September 11, 2009. Available at: http://www.brisbanetimes.com.au/national/doctors- circumspect-on-circumcision-20090910-fjep.html [Accessed September 4, 2013].

16 Forbes D. No evidence to support routine circumcision. Sydney Morning Herald, 12 September 2009; http://www.smh.com.au/news/opinion/letters/no- evidence-to-support-routine- circumcision/2009/09/11/1252519635874.html?page=fullpage

17 The kindest cut? Sunday Night program. Seven Television Network. May 24, 2009. YouTube. http://www.youtube.com/v/7yDvL4hNny4 (8 August 2011, date last accessed).

18 Morris B. In favour of circumcision. Sydney: University of New South Wales Press; 1999.

19 Geisheker JV. The completely unregulated practice of male circumcision: human rights' abuse enshrined in law? New Male Studies 2013;2(1):18-45.

20 Yegane R-A, Kheirollahi A-R, Salehi N-A, Bashashati M, Khoshdel J-A, Ahmadi M. Late complications of circumcision in Iran. Pediatr Surg Int 2006;22:442-5.

21 Machmouchi M, Alkhotani A. Is neonatal circumcision judicious? Eur J Pediatr Surg 2007;17:266-9.

22 Moosa FA, Khan FW, Rao MH. Comparison of complications of circumcision by 'Plastibell device technique' in male neonates and infants. J Pak Med Assoc 2010;60:664-7.

23 Ungar-Sargon, E. On the impermissibility of infant male circumcision: a response to Mazor (2013). Journal of Medical Ethics 2013; epub ahead of print.

24 Lyons B. Male infant circumcision as a 'HIV vaccine'. Publ Health Ethics 2013;6(1):90-103.

25 O'Neill O. Autonomy and trust in bioethics. Cambridge: Cambridge University Press; 2002.

26 Erichsen JE. The science and art of surgery. 7th edition, London: Longmans; 1877;2:932 .

Conflict of Interest:

None declared

Permalink:
http://jme.bmj.com/content/early/2013/08/16/medethics-2013-101614.abstract/reply#medethics_el_16775

Response to:
Paper: Veracity and rhetoric in paediatric medicine: a critique of Svoboda and Van Howe's response to the AAP policy on infant male circumcision

Brian J Morris, Aaron A R Tobian, Catherine A Hankins, Jeffrey D Klausner, Joya Banerjee, Stefan A Bailis, Stephen Moses, Thomas E Wiswell 

J Med Ethics medethics-2013-101614Published Online First: 16 August 2013 doi:10.1136/medethics-2013-101614
Permalink:
http://jme.bmj.com/content/early/2013/08/16/medethics-2013-101614.abstract

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