Flawed Circumcision Defense: Children’s Urology, Austin

Posted: February 3rd, 2015 | Author: | Filed under: Ethics, FCD, Media Marketing, Parenting, Surgery | 1 Comment »

Hey, a press release (Links omitted):

New Austin parents wishing to heed the American Academy of Pediatrics and the Centers for Disease Control recent guidance on circumcision, which endorse the procedure because of resulting health benefits, have access to a new in-office resource dedicated to circumcision — the Newborn Circumcision Clinic at Children’s Urology.

The CDC’s draft proposal aimed at medical providers has not been formalized as a recommendation. It says so in the public notice (emphasis added):

“… The draft recommendations include information about the health benefits and risks of elective male circumcision performed by health care providers.”

Even though the press release acknowledges the draft status of the proposed recommendations, Children’s Urology uses the draft proposal to sell non-therapeutic circumcision. That’s odd.

It’s odder still because the CDC’s draft proposal ignores the direct physical costs of circumcision to the patient. The CDC’s draft proposal stumbles on the ethical analysis of applying the potential benefits to healthy children. The CDC’s draft proposal fails to mention or evaluate many options for prevention and treatment of maladies that are less invasive and more effective than circumcision, such as the HPV vaccine. The CDC’s draft proposal is half-baked. Half-baked is a poor basis for eliciting any level of informed consent.

There’s a reason this next paragraph closes the Notice document:

In addition to obtaining public comment on the draft Recommendations, CDC considers this document to be important information as defined by the Office of Management and Budget’s (OMB) 2004 Information Quality Bulletin for Peer Review and, therefore, subject to peer review. CDC will share the summary of public comments with external experts who conduct a peer review of the evidence on this topic. Their review will include an evaluation of completeness, accuracy, interpretation, and generalizability of the evidence to the United States and whether the evidence is sufficient to support the draft counseling recommendations.

No worries, though. The Newborn Circumcision Clinic at Children’s Urology is ready to sell new Austin parents surgery for their healthy sons. It says so in their press release. Jillian Moser, PA-C, or someone on the circumcision provider team, will circumcise the healthy baby if he’s six weeks old or younger, weighs 10 pounds or less, and has normal appearing anatomy. The circumcision provider team does not require a boy to need any form of intervention before they’ll perform surgery. One might be inclined to think that a strange requirement to dismiss. However, lest healthy newborn boys worry they might not be in good hands, Children’s Urology knows what healthy newborn boys care about most for their genitalia: the comfort of their parents.

“Our Newborn Circumcision Clinic offers a comfortable, in-office experience for families interested in following the recommendations and pursuing circumcision for their son,” said Leslie McQuiston, MD, pediatric urologist at Children’s Urology.

Of course, it’s curious that Leslie McQuiston, MD, believes the CDC’s draft proposal a) targeted parents and b) recommends circumcision of newborns. Either of those beliefs suggests that Dr. McQuiston hasn’t read the CDC’s draft proposal (or the longer document that supports the draft proposal). The claimed link to the CDC’s draft proposal in her clinic’s press release loads a PDF announcing the draft proposal for public comment. Since Children’s Urology doesn’t seem to know where the actual draft proposal is located, it’s possible they haven’t read the draft proposal, which would be understandable. Who has time for reading dense material when so much science needs urgent applying to healthy children? Healthy children can’t possibly wait for the draft proposal to be finalized, much less wait until they might have a need for the most radical intervention. The science of newborn male genital anatomy isn’t scientific without a scalpel, after all. Duh. Everybody knows that.

Maybe the confidence of new Austin parents wouldn’t be so high after considering the totality of evidence from Children’s Urology’s press release. Trust them, though. Right in the press release, it says their clinic is “the premier pediatric urology practice in Central Texas,” and that it “specializes in the medical and surgical treatment of genitourinary conditions from birth through adolescence.” That’s great, and probably true, but we’re all now thinking the same thing. Okay, maybe the folks at Children’s Urology aren’t thinking this, but most of us not selling surgery on healthy children to parents using a flawed draft proposal are thinking it. Circumcision isn’t a genitourinary condition. I know, right? It seems obvious. But, on the contrary, we’re all wrong. It says so right on Children’s Urology’s site, under Conditions We Treat.

Genitalia

  • Ambiguous Genitalia¹ (DSD)
  • Chordee
  • Circumcision
  • Concealed / Hidden Penis
  • Epispadias
  • Hypospadias
  • Labial Adhesions
  • Meatal Stenosis²
  • Micropenis
  • Phimosis

I know, I know. It’s weird that circumcision is offered to treat the genital condition, “circumcision”. It’s weirder, I guess, because Children’s Urology convinced me we agree. Parents, doctors, activists, the AAP, the CDC, and Children’s Urology all need to work together to eradicate this awful scourge, circumcision, that somehow persists for healthy boys in modern society.

¹ I’ll refrain from speculating on this item because I do not know what Children’s Urology recommends for these children.

² It’s worth remembering that meatal stenosis and adhesions are possible complication from circumcision (i.e. the treatment for the condition, “circumcision”).


The AAP Discounts Its Patients’ Right to Physical Integrity

Posted: March 23rd, 2013 | Author: | Filed under: Ethics, FCD, Law, Logic, Parenting, Politics, Public Health, Science, STD, Surgery | No Comments »

In “Cultural Bias in the AAP’s 2012 Technical Report and Policy Statement on Male Circumcision”, Morten Frisch, MD, PhD, et al (pdf) criticize the AAP’s revised policy statement on circumcision. In part, they state:

The most important criteria for the justification of medical procedures are necessity, cost-effectiveness, subsidiarity, proportionality, and consent. For preventive medical procedures, this means that the procedure must effectively lead to the prevention of a serious medical problem, that there is no less intrusive means of reaching the same goal, and that the risks of the procedure are proportional to the intended benefit. In addition, when performed in childhood, it needs to be clearly demonstrated that it is essential to perform the procedure before an age at which the individual can make a decision about the procedure for him or herself.

They raise many issues surrounding the AAP’s focus on UTIs, penile cancer, STDs, and HIV. They conclude that non-therapeutic circumcision “fails to meet the commonly accepted criteria for the justification of preventive medical procedures in children.” Even ignoring their critique of the applicability of the scientific studies involved in the AAP’s revised policy statement, they are convincing. Their ethical argument is powerful.

The response by the AAP’s Task Force on Circumcision is intriguing and bizarre. It’s intriguing because it raises potential issues with what Frisch et al wrote about the science. This section is worth discussing, but not by me. I see the points on both sides. It’s difficult for either to squeeze every helpful detail into a few pages. For this, I’ll leave it with my usual statement. I am willing to accept the claimed benefits, however faulty they may be. The ironclad ethical case against non-therapeutic child circumcision is no weaker if all of the AAP’s criticisms have full merit.

Its response is bizarre for the ethical issues the Task Force continues to dismiss and ignore.

First, responding to the claim that the Task Force suffered from cultural bias:

… Although that heterogeneity may lead to a more tolerant view toward circumcision in the United States than in Europe, the cultural “bias” in the United States is much more likely to be a neutral one than that found in Europe, where there is a clear bias against circumcision. …

That (claimed) neutrality is the problem in the AAP’s revised policy statement on male circumcision. They imagine that there is no right answer to this ethical question. Here, the physical integrity of a healthy child is surgically violated without his consent. The law recognizes a single correct answer for female minors on the same ethical question. The implicit conclusion that male minors possess a lesser right to their physical integrity than their sisters is indefensible. It doesn’t matter that potential benefits exist from circumcision. Frisch et al demonstrate this in analyzing the difference between consent and proxy consent for a non-therapeutic intervention.

The AAP continues its challenge:

… Yet, the commentary’s authors have, at no point, recognized that their own cultural bias may exist in equal, if not greater, measure than any cultural bias that might exist among the members of the AAP Task Force on Circumcision. If cultural bias influences the review of available evidence, then a culture that is comfortable with both the circumcised penis and the uncircumcised penis would seem predisposed to a more dispassionate analysis of the scientific literature than a culture with a bias that is either strongly opposed to circumcision or strongly in favor of it.

So, basically, the AAP’s Task Force is saying “I’m rubber, you’re glue”.

To the point, Frisch et al show that the cultural acceptability of circumcision is not a valid defense because there is a right answer to the ethical question involving this prophylactic surgical intervention on healthy children. The AAP missed the essential issue in its recommendation. The ongoing American experiment with circumcision is a reasonably-inferred explanation. Frisch et al emphasize the child in non-therapeutic child circumcision. The AAP continues to emphasize only circumcision, with the children being a distant abstract. That is the problem, regardless of the reason.

For the purpose of those paragraphs, I pretended that the AAP’s claim that the US is neutral on infant circumcision isn’t laughable nonsense. On the basis of individual opinions, I think we’re probably the fifty-fifty nation they imagine. Institutionally, both medically and politically, we are very much a pro-circumcision nation. The Task Force stated a truth, while missing it, in its Technical Report:

… Reasonable people may disagree, however, as to what is in the best interest of any individual patient or how the potential medical benefits and potential medical harms of circumcision should be weighed against each other.

The factually-unprovable statement in the Abstract that the “preventive health benefits of elective circumcision of male newborns outweigh the risks of the procedure” is the evidence that the AAP is not a pillar of neutrality on non-therapeutic male child circumcision. The Task Force thinks the subjectivity it mistakenly presents as a valid general conclusion in its Abstract may reasonably be taken into consideration for circumcising an individual by proxy consent. If they understood the ethical implications, they would acknowledge that it must only be taken into consideration by the individual for his own healthy body. The neutral position presents facts and lets the individual choose. The biased position lets someone else impose a permanent, unnecessary intervention for the individual.

The Task Force includes a section, Age at Circumcision, in which their argument is that many minors make their sexual debut before the age of majority and some of those people are irresponsible with regard to condoms. The Task Force argues these two facts render it acceptable for parents to make their son’s circumcision decision for him. It views parents through an ideal, rather than the reality of human decision-making where a child must live with the permanent consequences of an unnecessary decision. Individuals are just part of a statistic.

When the Task Force finally gets to the ethical issues, it whiffs again:

… The authors’ argument about the basic right to physical integrity is an important one, but it needs to be balanced by other considerations. The right to physical integrity is easier to defend in the context of a procedure that offers no potential benefit, but the assertion by Frisch et al of ‘no benefit’ is clearly contradicted by the published scientific peer-reviewed evidence. …

Because there are potential benefits, we may discard the supremacy of the basic human right to physical integrity for the healthy child? That’s ridiculous. They don’t say it directly, but their conclusion for parents making their son’s choice endorses it in reality. With this thinking, any number of extreme surgical interventions could be justified on a healthy child because they might offer some benefit at some point. We should at least research any possible intervention to make sure we’re not missing some benefit that could decrease some risk, if that really is an acceptable approach. Or we could be rational and set aside our long-held cultural acceptance of this unethical procedure, but that’s harder to defend than fear, I guess.

The second statement, the “assertion by Frisch et al of ‘no benefit'”, is not supported by my reading of their paper. They do not state there is ‘no benefit’ to circumcision. They question the strength of the benefits and their applicability to children, particularly because less intrusive methods to achieve these benefits are available. The Task Force builds a straw man instead of confronting the ethical issues.

Finally, the Task Force asserts the “right to grow up circumcised“:

Frisch et al appeal to the ethical precept “First, do no harm,” but they fail to recognize that in situations in which a preventive benefit exists, harm can also be done by failing to act. Whereas there are rare situations in which a male will be harmed by a circumcision procedure, …

I’m interrupting the excerpt to correct this inaccurate statement. Every circumcision inflicts harm, including loss of normal tissue and nerve endings, as well as scarring. Some circumcisions inflict more harm than expected or intended. The Task Force conflates intent and outcome.

… it is also true that some males will be harmed by not being circumcised. Simply because it is difficult to identify exactly which individuals have suffered a harm because they were not circumcised should not lead one to discount the very real harms that might befall some men by not being circumcised. …

I don’t discount the real harms some will experience from the risks in being alive with a normal human anatomy. I dismiss their relevance in this context. It’s a dumb standard for evaluating what may be done to a healthy child without his consent. Life can never be lived without risk. If a male is worried enough about the minimal risks posed by his foreskin, he can elect to be circumcised with his own informed consent. But the reverse is not true. A male who is circumcised at birth can’t recover his foreskin if he would not trade his foreskin¹ for the proposed benefits. Individual choice is the valid, superior ethical position.

Their conclusion:

… There is no easy answer to this issue ethically. Regardless of what decision is made on behalf of a young male, harm might [ed. note: will, if the decision is circumcision] result from that decision. That is precisely why the AAP task force members found that this decision properly remains with parents and that parents should have information about both potential benefits and potential harms as they make this decision for their child.

There is an easy answer to this issue ethically. Non-therapeutic genital cutting on a non-consenting male is unethical. It inflicts guaranteed harm to minimize already tiny risks. This is the same easy answer we draw for females. We know parents shouldn’t make this decision unless it is “necessary to the health of the person on whom it is performed” when the person on whom it is performed is female. We’ve legislated this knowledge. The right to physical integrity is easy to defend. The AAP has an ethical duty to defend it for all children, including males.

¹ Full quote from AAP Task Force on Circumcision member Dr. Douglas Diekema: “[Circumcision] does carry some risk and does involve the loss of the foreskin, which some men are angry about. But it does have medical benefit. Not everyone would trade that foreskin for that medical benefit.”


Dumbest Sentence I’ve Read Today

Posted: February 5th, 2013 | Author: | Filed under: Ethics, Pain, Parenting, Surgery | No Comments »

From the Anne Arundel Medical Center’s information page on (infant) circumcision, in the “How is circumcision performed?” section:

Circumcision is performed only on healthy babies.

I will never understand how medical service providers can recognize that and still think nothing is wrong with their participation in their imposition of this non-therapeutic surgery on their patient.