Recent restatements of the case for routine circumcision of normal male infants and boys typically base their arguments on a range of medical evidence showing circumcision to have a protective effect against certain pathological conditions. It is then assumed that this evidence leads automatically to a clinical recommendation that circumcision should either be “considered” or strongly urged. Closer analysis reveals that the recommendation of infant or child circumcision has less to do with the medical benefits than with the historic origins of the procedure, the convenience to the operator and the status of the patient. It is further suggested that it is not clear that the medical benefits of infant or child circumcision outweigh the risks and harms, and that this style of advocacy fails to pay due regard to basic principles of bioethics and human rights that are accepted in other areas of medical practice.

The ultimate popularity of circumcision depended not on convincing normal men to undergo the ordeal of surgery, but on targeting a group of patients who could not object. —David Gollaher

The controvertists, answered my father, assign two and twenty different reasons for it: others indeed, who have drawn their pens on the opposite side of the question, have shewn the world the futility of the greatest part of them. —Laurence Sterne, Tristram Shandy

Recent restatements of the case for non-therapeutic circumcision (NTC) of normal male infants and boys rest their case on the proposition that the benefits are so great and the risks so small that the operation should be widely (perhaps even universally) performed.1 They also assume that circumcision will be performed in infancy or early childhood, and propose (usually without detailed argument) that removal of the foreskin from non-consenting children is permissible within accepted principles of bioethics and human rights. When challenged on these points, advocates argue that infancy is the best time for the operation because it is simpler and cheaper at that age, provides the greatest benefits, and permits parental choice. In this article, it is argued that these propositions are medically and logically questionable, that it is far from certain that circumcision provides significant net benefit to males in developed countries, and that the preference for circumcising infants (rather than recommending the operation as a health precaution to competent adults) has more to do with history, habit, and power than with the interests of the child.

NTC of normal male infants and boys has been such a familiar feature of Anglophone medical practice that it is difficult to appreciate what an anomaly it is. Surgical removal of body parts normally requires proof of pathology, efforts at non-surgical (medical) cure, and valid informed consent. In the case of circumcision of healthy male minors, none of these conditions is met. In this article, it is argued that the reasons for this peculiarity are not to be found in the familiar litany of benefits and risks advanced by circumcision advocates and financially interested providers; they must rather be sought in the history of medical knowledge, the structure of the profession, and the advance of technology. As historian David Gollaher points out, had circumcision not become established in Anglophone societies in the Victorian era, and in view of the development of evidence-based medicine, the advance of bioethics and the recognition of children’s rights since that time, “no physician would dream of proposing such a thing today.” Furthermore, considering the parallel case of female genital cutting/mutilation, he suggests that if “circumcision [of boys] were confined to developing nations, it would by now have emerged as an international cause celebre, stirring passionate opposition from . . . the global human rights community” (Gollaher, 2000, p. xiv). Although there are community-based anti-circumcision movements in many countries, particularly the United States, it remains true that the response from mainstream human rights and bioethical institutions has been surprisingly muted (Carpenter, 2014).

A Brief History of Routine Medical Circumcision Circumcision of boys was introduced in mid-19th-century United Kingdom and United States as a means of controlling manifestations of juvenile sexuality (principally “masturbation,” by which was meant any fondling of the genitals) and as a treatment for what became known as “congenital phimosis” (Darby, 2005; Glick, 2005; Hodges, 2005). Under the influence of nerve force theory, phimosis (i.e., a tight and/or non-retractable foreskin) was blamed for a host of pathological conditions, from epilepsy to bed-wetting. It was also seen as an incitement to penis fondling, and thus to masturbation, then regarded as both a moral crime and the cause of many diseases, both real and imaginary,2 and behavioral problems. At first, circumcision was performed ad hoc on boys caught playing with their penis or found to have an adherent or otherwise non-retractable foreskin. But as doctors discovered the scale of these problems—hardly surprising, as nearly all boys masturbated, and a tight, non-retractable foreskin is the normal condition of the juvenile penis (Agarwal, Mohta, & Anand, 2005; Cold & Taylor, 1999)—they wondered whether it was their duty as far-sighted health providers to take action before these problems produced their damaging consequences. The transition of circumcision from a case-by-case therapy to a general prophylactic was registered in Dr. Norman Chapman’s observation that the incidence of adhesive foreskins was probably far higher than people realized. Because “a long and contracted foreskin” was so often a source of “secondary complications,” he proposed in 1882 that it was “always good surgery to correct this deformity . . . as a precautionary measure, even though no symptoms have as yet presented themselves” (Gollaher, 2000, p. 84). He might well have been following the advice of Erichsen’s (1877)Surgery: So great are the evils resulting not only from congenital phimosis, but from an abnormally long, though not phimotic, prepuce, that it is only humane and right from a moral point of view, to practise early circumcision in all such cases. (Vol. II, p. 932) If it was scientifically valid, it had to be morally right. Another U.S. doctor who had become a circumcision convert after discovering that it could cure brass poisoning went further: Whether it be curative or not it [circumcision] is conservative, and removes one source of irritation from an exquisitely sensitive organ. I would favour circumcision, however, independent of existing disease, as a sanitary precaution . . . (1) The exposure of the glans to friction etc. hardens it, and renders it less liable to abrasion in sexual intercourse, and consequently venereal ulcer. (2) It is acknowledged to be useful as a preventive of masturbation. (3) It certainly renders the accident of phymosis and paraphymosis impossible. (4) It prevents the retention of sebaceous secretion and consequent balanitis. (5) It probably promotes continence by diminishing the pruriency of the sexual appetite. (Gollaher, 2000, p. 85) As Gollaher (2000) remarks, these declarations and many like them represent an important transition in thought: Circumcision becomes not just a treatment for existing problems, but an anticipatory intervention designed to prevent possible problems in the future. By the turn of the century, it was accepted that circumcision was generally desirable as a means of preventing masturbation, phimosis, venereal disease, certain forms of cancer, and various minor penis problems loosely grouped under the catch-all heading of “balanitis,” as well as reducing the male sex drive (Darby, 2005). Most of the real medical problems in this list occurred in adults rather than children, but because adult men were not exhibiting much eagerness to get themselves circumcised, the doctors concentrated on the younger generation. As Gollaher (2000) sums up, “The ultimate popularity of circumcision depended not on convincing normal men to undergo the ordeal of surgery, but on targeting a group of patients who could not object” (p. 100). Take-up of the procedure was inhibited, however, by the difficulty of the operation (often quite messy and bloody, especially in infants and young boys), the lack of suitable instruments, and the high incidence of complications, including deaths from infection and bleeding. These obstacles were gradually overcome by the progress of aseptic surgery and, in the 1930s, with the development of effective antibiotics and a purpose-built device—the Gomco clamp. This was the brainchild of U.S. gynecologist Hiram Yellen and businessman Aaron Goldstein, owner of the Goldstein Manufacturing Company (Yellen, 1935). They claimed to have invented an instrument so elegant in design and so simple to use that even an untrained intern, accoucheur or general practitioner (GP) could easily perform circumcision procedures with a negligible incidence of complications and a neat result. Whatever the truth of those claims, the device took off, and it remains the instrument of choice among U.S. circumcision providers to this day, rivaled only by the Plastibell (Glick, 2005; Wan, 2002). In 1941, Alan Guttmacher, professor of obstetrics at Johns Hopkins, recommended the “gadget,” and discussed “phimosis” (foreskin tightness) and prevention of masturbation among the reasons the baby should be circumcised (Guttmacher, 1941). The ubiquity of routine infant circumcision in the United States was thus the result, not of any clinical trials or other research demonstrating the value of circumcision in improving child health, but of a power play within the medical profession and the temptations of technology. The Gomco clamp allowed the obstetricians to become the dominant players in the circumcision market, replacing the midwives who had previously been responsible, and cutting out the pediatricians and urologists (who were left with the task of repairing the botches) because they could perform the operation as a routine part of the childbirth process at a significantly lower cost to the parents: Unlike operations performed by surgeons, Gomco circumcisions were done without anesthetic. Contrary to Yellen’s claim, the Gomco did not ensure “bloodless” surgery, but its design characteristics did produce a standardized, radically denuded organ, which has come to be widely regarded as the “normal” condition of the U.S. penis. Specialists in women’s health and midwifery thus became the branch of the medical profession with prime responsibility for delicate operations on intimate parts of the male body of which they had no expert knowledge, and it was the incorporation of circumcision as a routine phase of childbirth that has been the most important factor in the persistence of NTC in the United States (Cohen, 2011; Darby, 2013b; Hodges, 1997). The non-development of this division of professional responsibilities in other countries that adopted circumcision (the United Kingdom, New Zealand, Australia, Canada) helps to explain why routine circumcision has largely died out in these regions. The fact that it was the pediatricians who saw the complications helps to explain why they were the ones who took the initiative in discouraging the practice (Leitch, 1970). The importance of the obstetricians in promoting routine circumcision of infants is further highlighted by a key paper from 1953 that consolidated the principle that the earlier circumcision was performed, the better. According to the authors, Richard Miller and Donald Snyder, the principal “indications” for circumcision were to promote “hygiene” and to prevent phimosis, venereal disease, and cancer of the penis. Additional (disputed) advantages were to discourage masturbation, increase the male libido, and promote longevity. Despite the fact that the only real benefits in this list accrue to adults rather than children, the authors went on to list nine additional reasons as to why circumcision should ideally be performed immediately after birth, and certainly before mother and child are discharged from the hospital. These include (a) greater safety, (b) lower incidence of complications, (c) faster healing, (d) convenience, (e) opportunity for close observation, (f) simpler to ensure sterile environment, (g) operation wakes sleepy babies up,3 (h) faster healing and lower incidence of infection, and (i) less pain than if done later. The authors had little evidence for any of these assertions, but it is clear that the most important factors in their mind were not the health and well-being of the child, but expediency and cost. As they explain under the “Convenience” heading, Prior to this new plan . . . a line-up on Sunday morning was routine. It meant an extra hospital trip, a good deal of unavoidable delay between cases, and the resulting traffic problem in the birth rooms was prodigious. Under the present regime the obstetrician finishes his episiotomy, walks across the hall and circumcises the infant, and is finished with the whole business. The time saved for both the physician and nursing staff is considerable. (Miller & Snyder, 1953, p. 4) So impressed were Miller and Snyder with the efficiency of their production line that they returned to its advantages in their conclusion, there making the additional points that “there is no conflict in the scheduling of cases, and no babies are forgotten and left uncircumcised” (p. 10). For all those reasons, “as well as those of economy, convenience, safety, rapidity of healing and close observation,” they continued, “we feel that immediate circumcision of the newborn male infant might well be more universally adopted” (p. 10). As indeed it was, though only in North America. Although the practice became rare in the United Kingdom and began to decline in Australia and New Zealand during the 1950s, routine circumcision did not reach its peak incidence in the United States until the 1970s (Darby, 2013b; Hodges, 1997; Wallerstein, 1980).

The Opinion of Child Health Authorities It is also significant that, with one semi-exception, all the medical organizations that have issued policy statements on infant or child circumcision have found that there is no justification for it as a routine health precaution.7 The exception is the American Academy of Pediatrics (AAP), whose 2012 policy statement has been widely (though inaccurately) interpreted as a recommendation for circumcision. In fact, the AAP does not recommend the operation or regard it as medically necessary, but concludes merely that the benefits exceed the risks. Even this moderate position has been criticized on empirical grounds by child health experts (Frisch et al., 2013) and on logical and philosophical grounds by others (Darby, 2015; Svoboda & Van Howe, 2013).8 What is interesting about the AAP policy is not its central contention, but a couple of subsidiary conclusions that are not backed up by any real evidence at all: first, that it is legitimate for parents and doctors to circumcise for cultural and religious reasons; and second, that it is appropriate for medical insurance systems (both government and private) to pay for circumcision procedures. To take the second point first, the AAP offers no argument as to why it is acceptable for systems intended to improve health to pay for cultural or religious rituals. As Adler (2011) argues, if a medical procedure is neither clinically necessary nor recommended, it may be unlawful for Medicare to fund it. As to the first point, I do not wish to make an argument about the ethics of religious and culturally motivated circumcision, but point out that the timing of the operation in these instances is not dictated by health considerations or the best interests of the child, but by the traditions of the culture. Most circumcising cultures perform the operation around puberty, signifying the boy’s (and in most cases also the girl’s) transition from childhood to adult responsibility. Exceptions to this pattern are found in Islam, which sets no specific age and imposes no obligation on parents to circumcise their children (Aldeeb Abu-Sahlieh, 1994); and in Judaism, which (uniquely) prescribes circumcision in early infancy (the eighth day). There was never any “health logic” to these rules, which were purely a matter of tribal custom or religious tradition (Glick, 2005). As indicated above, the AAP is quite isolated in its support for circumcision, moderate and equivocal though it is. More typical of world opinion are the policies of the Royal Australasian College of Physicians (RACP) and the Canadian Paediatric Society (CPS). After a comprehensive analysis of the relevant literature, the RACP concluded 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 or New Zealand” (RACP, 2010, p. 5). The CPS, Fetus and Newborn Committee (2015) concurs, “While there may be a benefit for some boys in high-risk populations . . . the Canadian Paediatric Society does not recommend the routine circumcision of every newborn male” (p. 311). What makes the position of both these bodies all the more significant is that they reached this conclusion on the basis of a narrow calculus of risks and benefits and paid little attention to the value of the foreskin to the individual and his possible wishes in later life. There has never been a comprehensive assessment of the complications of circumcision, some of which (such as excessive tissue removal, leading to uncomfortable erections) may not become evident until after puberty (Peterson, 2001). The value of the foreskin itself as a functional body part that the individual might want to keep and enjoy has rarely been factored into such harm–benefit calculations as have been attempted.9 Both the reviews mentioned above and the policy statements of medical authorities acknowledge evidence from Africa that circumcision of adult males can reduce their risk of acquiring HIV through unprotected intercourse with an infected female partner in regions of high heterosexual HIV prevalence. But they point out that these conditions are not present in developed countries and that children, not being sexually active, are not at risk of sexually transmitted HIV (Bossio et al., 2014; Lyons, 2013). It is, therefore, far from clear that circumcision does confer the benefits claimed by its promoters, undermining the premise of both versions of the argument outlined above.

Questions of Logic and Evidence These considerations bring us to the next stage of the argument: that even if premise 1—that circumcision did confer lifelong health benefits—were granted, it would not follow that the operation may ethically be performed on minors. The argument of those who advocate routine neonatal circumcision is now so familiar that it hardly needs detailed exposition: The health benefits of circumcision accrue to the circumcised infant, on a probabilistic basis, at future points in his life, some in infancy or childhood, but the bulk (and most significant) in adulthood. They include such advantages as a reduced risk of urinary tract infections (UTIs), phimosis and minor penile problems in childhood, and of STIs and rare forms of cancer in maturity. This list corresponds closely to the Victorian trilogy that circumcision prevented masturbation in childhood, syphilis in maturity, and cancer in old age (Darby, 2005). The principal pillar of the case for circumcision is not, therefore, the claim that it meets the health needs of the infant or child, but that it improves the health prospects of the adult he will later become. These future benefits, it is claimed, not only outweigh the risks and harms (physical, psychological, and emotional) of the procedure but also justify (or even require) the widespread adoption of circumcision as a preventive measure of public health. None of these claims follows logically from the evidence. Because the major benefits claimed—reduction in the risk of STIs (including HIV)—can be enjoyed only by mature and sexually active males, the logical prescription arising from the premise is to provide the information to young adults and allow them to elect to have their own foreskins removed if they judge it to be prudent and are willing to face the risks and losses. This would correspond to voluntary medical male circumcision (VMMC), as recommended by the World Health Organisation in regions with epidemic levels of heterosexually transmitted HIV and low circumcision prevalence. The fact that few adult males in developed nations do choose to have themselves circumcised,10 and that forcing men to submit to circumcision would be a criminal assault under any legal code (or, if legally sanctioned, a gross violation of personal autonomy and individual human rights), is in itself a powerful argument that it would be unethical to perform the same operation on infants or children, who cannot resist.

Bioethical and Human Rights Principles Because most circumcision advocacy places little emphasis on bioethical and human rights issues, it is well to be reminded of the basic principles of bioethics as set out by Beauchamp and Childress (2009): autonomy (requiring respect for informed choice), non-maleficence (not doing harm), beneficence (doing good), proportionality (ensuring that the outcome of the intervention provides a significant net benefit to the patient in relation to the risks run and the losses sustained), and justice (treating the person fairly). To establish the legitimacy of circumcision of non-consenting children, it is necessary to show that the operation is consistent with these principles, but it is difficult to find any circumcision advocacy that discusses them in detail. Some circumcision advocates seek to reverse the onus of proof by suggesting that not circumcising a boy is a violation of his human rights because it denies him both protection against the health risks attributable to the foreskin and the advantages accruing from its removal (Bates et al., 2013). But this is to assume that the benefits of circumcision are as great as claimed (the very point in dispute), that the foreskin is worthless and its removal not a deprivation or even a harm, and that the boy’s own possible future preferences are of no account. To take the question of harm, despite arguments to the contrary by some moderate (parental choice) supporters of NTC, it cannot plausibly be maintained that excision of the foreskin is not a harm.15 Removal of normal tissue is not necessarily a harm, for few people would be likely to mind if a healthy appendix was extracted as a precaution, as it is imperceptible and has no psychological significance. The genitals are a different matter: A visually prominent component of a body part as sexually significant as the penis will never be regarded with the same indifference, neither by admirers nor detractors. Some advocates have likened circumcision to minor surgical procedures such as cleft palate or hare lip repair or even orthodontic treatment; but the comparison fails because these are therapeutic procedures aimed at restoring anatomical normality and full physiological functionality. Moreover, as Brian Earp (2015b) points out, there is no evidence that the beneficiaries of these interventions object to what was done to them. While we can observe a voluble anti-circumcision movement in the United States and elsewhere,16 and cohorts of men who deeply resent their circumcision and seek to restore their foreskins (Watson, 2015), it is not possible to detect any anti-cleft lip repair movements or a surge of online communities dedicated to recovering their crooked teeth. Leading exponents of the view that parents have the right to circumcise their boys acknowledge that circumcision is a harm, but argue that it is not sufficiently harmful to warrant prohibition (Benatar & Benatar, 2003; Cannold, 2006). That may be so, but the argument here is not whether NTC of minors should be illegal, but whether it is of “compelling” net medical benefit and ethically permissible.

Open Future, Best Interests, and Substituted Judgment Fundamental as they are, the Beauchamp and Childress principles are not the only guidelines to be considered when we perform surgical procedures on children. There is also the question of the child’s right to an open future, the best interests and substituted judgment tests, and the increasingly prominent matter of human rights. These include a person’s right to physical integrity, as embodied in much Western law and custom, and in certain international human rights treaties and declarations. These rights are now generally accepted as applying to girls, but if they are human rights they must, logically, apply to boys as well (DeLaet, 2009; Hellsten, 2004; James, 1994; Johnson, 2010; Svoboda & Darby, 2008). In the Victorian era that gave birth to circumcision, children were to be seen but not heard and medical ethics were rudimentary; but during the 20th century, the slow human rights revolution (Pinker, 2011) that began with John Locke reached children, who are now seen as possessing the same sort of rights to bodily integrity and protection from harm that adults enjoy (Orend, 2002). This does not mean that children have equal rights as adults, but, as Brennan and Noggle (1997) argue, that they are entitled to the same moral consideration as adults because they are persons. At the same time, children may be treated differently from adults by virtue of their immaturity and dependent status, and parents have real but limited authority to direct their upbringing. As Tobin (2013) recently argues, because children have interests, they also have rights, even though they (temporarily) lack the capacity to articulate, much less enforce, them. The concept of the child’s right to an open future can provide a bridge between the child’s temporary lack of capacity and the preservation of his long-term interests. The child’s right to an open future is an accepted principle in legal philosophy, applied to bioethical issues by Dena Davis (1997, 2001) and in recent times specifically to circumcision (Darby, 2013a; Hainz, 2015; Sarajlic, 2014) and surgical treatment of hypospadias (Carmack, Notini, & Earp, 2015). The principle holds that children are adults-to-be, and that it is the duty of parents to make efforts to preserve and protect their options so that they can make choices about matters of personal preference for themselves in adulthood. This applies not only to the provision of affection, food, shelter and education but also to freedom from irreversible and potentially harmful decisions about their body that they might later resent. If this extension is valid, the open future principle would allow parents to compel children to brush their teeth and prevent them from getting obtrusive marks such as a tattoo, a nose-ring, or permanent genital modifications, and at the same time would constrain them from imposing such modifications. It would preclude deaf parents who believe that deafness is a valid culture from deliberately causing their children to be deaf. Forcing children to clean their teeth, preventing them from smoking, and preserving their foreskin all have the same rationale and objective: to maintain the body for future use and to ensure that the future adult will be able to make his own decisions about such matters when he becomes responsible for his own self-management. “Best interests” and “substituted judgment” are two tests that may be applied when decisions have to be made on behalf of those incompetent to make them for themselves, whether minors or disabled adults. “Best interests” are the long-term interests of the person as a person, taking account of the society in which he or she lives, interests, skills, hopes, wishes, values, self-image (among others), and if a minor the person’s interests in the future, as an adult. In the case of Re J—Child’s Religious Upbringing and Circumcision (2000), for example, an English court determined that it would not be in his best interests for a 6-year-old boy to be circumcised merely because his Muslim father wanted him to be. A similar conclusion was reached by the Family Court of Australia (2003) in the case of K and H. It would, however, be in the child’s best interests to be given necessary therapeutic medical treatment, such as a life-saving blood transfusion, even if his parents were Jehovah’s Witnesses, whose religion prohibited such procedures. It would also be in his best interests to be vaccinated against serious diseases, such as hepatitis B, if he was at risk of infection (say from a parent with the disease), even if the parents were philosophically opposed to vaccination (Isaacs, 2009). In both cases, the child’s welfare trumps the parents’ wishes. When medical treatment is either necessary to save a person’s life, or provides proven and substantial benefits (such as immunity to serious diseases) without harm, loss of body parts or function, and without a significant risk of complications, it is acceptable to provide it without the informed consent of the recipient. The other test is the substituted judgment test—the option that an incompetent person would be most likely to choose for himself if he were competent to form and express an opinion (Beauchamp & Childress, 2009). Analyzing this concept, the legal scholar James Dwyer (1994) suggests that children should not have fewer rights than or be treated with less consideration than incompetent adults. Dwyer acknowledges that infants and young children would not have shown much evidence of preferences on any aspect of their lives, but does not regard this as invalidating the substituted judgment principle so long as there are reasonable grounds for determining what the incompetent person would choose if he or she were competent. One way of establishing the answer in relation to medical issues is to ask what competent adults choose when faced with the same question. Most adults would agree to a blood transfusion if it meant the difference between life and death, and most would agree to get vaccinated against a serious disease if they were likely to be exposed to it and at risk of infection. The case of circumcision is even more clear-cut: Because a negligible number of adult men in Western societies elect circumcision for themselves, we may reasonably infer that if the average minor were asked whether he wanted to get circumcised he would refuse.

The Case for Infant Circumcision? If the health benefits are not as great as claimed and the important ones can be secured by voluntary circumcision in adulthood, and if the ethical objections to NTC of minors are greater than circumcision advocates allow, it follows that the case for infant circumcision has not been made. The reasons given for insisting on it in commentaries by Tobian, Gray, Morris, and, with less enthusiasm, the AAP17 place too much emphasis on the wishes of adults and not enough on the interests and autonomy of the child. Indeed, they scarcely go beyond the narrow utilitarianism of Miller and Snyder: that it is simpler, more convenient, cheaper, less painful, and attended with fewer complications than if done later. The first three points show insufficient regard for the interests of the child, his autonomy, or even his personhood, but focus entirely on the needs of adults and impersonal health systems. They are questionable because they ignore the fundamental point that medical interventions are not normally permissible unless their intent, rationale, and result are to benefit the person being treated. Procedures intended to benefit other parties, as is the case if they are performed for reasons of economy, convenience, or simplicity (here meaning that a baby is more easily persuaded than an adult), fail both the non-maleficence and beneficence tests and are plainly unacceptable. By analogy, it is probably cheaper and more convenient to have sex with an unwilling 5-year-old than with an unwilling adult, but that does not make the practice desirable. If it is cheaper to circumcise children rather than adults this is only because infants are usually circumcised as part of larger process (the childbirth sequence), with inadequate anesthesia, or none at all (Bellieni, Alagna, & Buoncore, 2013; Paix & Peterson, 2012). Given the dense innervation of the foreskin (Cold & Taylor, 1999), any cutting in that area is intensely painful, no matter what the age, but circumcision is probably less painful for an adult because he can be given both effective anesthesia and post-operative pain control, and he can articulate his needs. To circumcise without effective anesthesia would be a gross violation of the non-maleficence principle and extremely cruel: even supporters of a parental right to circumcise regard such an omission as ethically unacceptable (Benatar & Benatar, 2003). Research into the effects and complications of circumcision is too inadequate for anybody to know whether it is safer and less harmful in infancy, childhood, or maturity.18 If mere cheapness is the aim of health care, the best policy is to avoid unnecessary surgeries (Van Howe, 2004). The “increased cost” argument is based on the false assumption that circumcision will be necessary at a later stage: In the vast majority of cases, circumcision will not be necessary, meaning that there will be no costs at all. A disturbing feature of much current circumcision advocacy is the underlying assumption that the biomedical evidence “speaks for itself”; once the evidence is available, public policy should follow automatically as a logical consequence. As de Camargo, Mendonca, Perrey, and Giami (2015) comment, however, this is a technocratic and authoritarian approach that over-simplifies the complexities of medical decision making, ignores social and other contextual factors, dismisses bioethical and human rights principles as nebulous, and considers “subjective” issues such as the value of the foreskin and the preferences of the individual to be irrelevant. Savulescu (2015) similarly warns against the tendency to “scientify” everything: “Evidence will tell us what to do, people believe. But what constitutes sufficient evidence is an ethical decision,” as is weighing risk and benefit (p. 30). “Ethics is not peripheral to medicine and research—it is central. What you study will determine what you find” (p. 30). We typically hear arguments that circumcision is justified or not justified on the basis that the benefits exceed the risks of the surgery or that the risks of surgery exceed the benefits. But the risk–benefit rule was devised for therapeutic procedures, where there is a pathological condition that requires treatment. In the case of normal male infants and boys, there is no pathology to treat, meaning that circumcision is a non-therapeutic procedure, and hence should be governed by far stricter rules. In the case of minors, who by definition cannot give consent, the rules should be stricter still. Furthermore, as Buchanan (1983) points out, risk–benefit equations are not merely clinical (objective) calculations, but moral judgments about a person’s values and how he wishes to manage his life. The principal quasi-ethical argument commonly advanced by circumcision advocates19 is that parents are entitled to make medical decisions for their children; because it is widely agreed that parents can provide surrogate consent for a child to be vaccinated, they can equally provide consent for a child to be circumcised. This proposition is highly dubious. Although circumcision advocates have sought to liken circumcision to vaccination, there are fundamental differences in mode of operation, effectiveness, and personal outcomes, both bodily and psychological (Forbes, 2009; Lyons, 2013). A logically invalid analogy does nothing to support the case for circumcision.

Parental Rights or Parental Duties? As for the parental rights argument, it is not parents who need rights over their children, because they already have full power over them. Parents have authority, but because children are vulnerable, and infants a powerless and even voiceless group, in need of special protection, they are the ones who require and possess rights, and society places limits, both moral and legal, on how parents may treat them. Parents may not sell their children into slavery, subject them to unreasonable corporal punishment, or have sex with them; on the positive side, they must nurture and care for their children, provide them with an adequate education, and socialize them into the ways of society. It follows that parents do not have an unfettered right to choose medical treatments for their children, and it has been argued that parents have no legal right to authorize controversial or non-recommended medical treatments for their children, and certainly not if it involves unnecessary removal of healthy body parts (Povenmire, 1998-99). Forty years ago, William Bartholome was concerned about the wide discretion conferred by proxy consent and disputed the assumption that parents had “the right to make all medical care decisions involving a minor child.” Because children, in his view, belonged primarily to themselves, he proposed the following principles for pediatric care: 1. Any proposed medical intervention that could be delayed, without significant adverse consequences, until the child could provide his own consent would be prima facie wrong. 2. Any medical intervention for which there is no demonstrable need would be prima facie wrong—e.g. circumcision. 3. Any medical intervention that holds out the prospect of demonstrable benefit to the child whose life or well-being were in jeopardy would be prima facie obligatory—e.g., immunizations. (Bartholome, 1981, pp. 271-272, 275) In other words, what parents have is an obligation to protect their children’s rights and provide appropriate, beneficial, and needed treatment that is manifestly in the child’s best interests, has regard to the open future principle, and satisfies the substituted judgment test—that it was a decision a reasonable adult would be expected to reach for himself. A parent is not entitled to provide a sick child with harmful, inappropriate, or spurious treatments (such as faith healing or bogus “alternative” cures), or to deny a healthy child vaccination against serious diseases of which he is at risk (Isaacs, 2009). Rejecting the argument that observance of a “harm threshold” is an adequate yardstick for parental decisions about medical treatment of children, Birchley (2016a, 2016b) argues that parents are not automatically entitled to deny them beneficial and necessary treatments; and, it follows that they are not entitled to impose harmful or unnecessary treatments. In these situations, medical personnel may be entitled (even morally obliged) to override parental wishes, either by insisting on a beneficial intervention to which parents object, or by refusing an intervention that parents have sought. It is reasonable for parents to have their children vaccinated against the risk of future diseases because such prophylaxis protects them and the community from diseases that affect them as children and does not deprive them of a normal body part. Vaccination may thus be assessed as being in the child’s best interests and also—as shown by the fact that adult men regularly get themselves vaccinated—as passing the substituted judgment test. As Beauchamp and Childress (2009) point out, Best interest judgments are meant to focus attention entirely on the value of the life for the person who must live it, not on the value of the person’s life for others. “Quality-of-life” judgments also concern only the individual’s best interests, not his or her worth to enhance another’s quality of life. (p. 140) It follows that, barring a genuine pathological condition for which circumcision is the only cure, the only person entitled to make a health-based decision about such surgery is the person who must live with the consequences.

Routine Peripubertal Circumcision? Recognizing that if circumcision does offer significant health benefits they do not apply until adulthood, some commentators have suggested that infant circumcision be abolished and replaced with “elective” circumcision in late childhood or early adolescence (around 11 years of age). As MacDonald (2011) points out, There is no new evidence that infant circumcision provides any added benefit to the neonate, infant or young child with respect to HIV and HPV protection. The potential benefit from circumcision only begins to accrue when the male becomes sexually active. (p. 872) Accordingly, “the important question for . . . pediatric societies is not about a change in infant circumcision recommendations, but rather the need to address whether there would be merit in routine peripubertal male circumcision.” This is an interesting idea, but there is clearly a difference between offering circumcision to an 11-year-old boy and performing it routinely at that age, as in South Korea or the Philippines (Glick, 2009; Kim & Pang, 2002), and MacDonald goes on to make the dubious suggestion that an 11-year-old can give informed consent. Although a boy at that age would indeed be more competent to give informed consent than he was at 6 weeks or 6 months, it is still difficult to accept that he would have sufficient competence to consent to an irreversible alteration to a central part of his genital anatomy. Few boys of that age would have adequate maturity of judgment or knowledge of both what the operation entailed and its short- and long-term consequences, and many would be subject to such strong parental, peer, and social pressures that they would not be capable of making a free choice. The earliest age at which a person is held to be competent to consent to sexual relations is 16 or 18; it is hard to see why the rules for irreversible genital alterations should be less strict than those governing sexual relations. MacDonald’s suggestion was picked up by the Canadian media, and attracted comments that demonstrated, yet again, the depth of the Anglophone assumption that circumcision means circumcision of infants. One medical practitioner was reported as stating that the idea was unacceptable because “If you explain to any 11-year-old what you were proposing, likely an 11-year-old would never consent to have that done.” Quite—for as a reader of the National Post (“Simon of Toronto”) commented, it would be hard to find a more convincing ethical argument as to why circumcision of children should not be done at all: That’s about as solid an argument against circumcision as anybody should need. Basically, he’s saying that the best reason to cut babies is because they can’t tell you to stop. It neatly—and brutally—clarifies the moral injustice of the practice. (Kirkey & Fraiman, 2011) The AAP (2012) concedes that Newborn males who are not circumcised at birth are much less likely to elect circumcision in adolescence or early adulthood. Parents who are considering deferring circumcision should be explicitly informed that circumcision performed later in life has increased risks and costs. (p. e760) So although the AAP does not recommend circumcision, it still puts strong pressure on parents to have it done. Brian Morris (1999) similarly admits that if the circumcision choice were left to them, many boys would make the “wrong” decision. “Parental responsibility must override arguments based on the rights of the child,” he writes, “parents have the legal right to authorise surgical procedures in the best interests of their children” (pp. 61-62). When they are old enough to give legal consent, males “are reluctant to confront such issues” and are neither “mature nor well-informed enough” to make the right decision for themselves. In other words, Morris concedes that if doctors waited until boys were old enough to make up their own mind, most would not consent to the operation. It would be hard to think of a stronger argument as to why circumcision should not be done before the person is able to provide informed consent.

Conclusion I have sought to show that recent restatements of the medical case for NTC of normal infants fail on three major points, one ethical, one medical, and one logical. They do not demonstrate that circumcision of non-consenting minors is permissible within accepted principles of bioethics and human rights; they fail to establish that the benefits are sufficiently great to outweigh the harms and risks; and, they do not show that circumcision must be performed in infancy to secure the major benefits claimed for it. Even if it were true that circumcision did confer all the health benefits claimed, and ignoring such unsettled questions as complications and the harms arising from loss of the foreskin, the ethical principles governing surrogate consent for surgical procedures on incompetent persons would not allow the operation to be performed on normal infants or other minors. Even if circumcision did confer a significant reduction in the risk of contracting certain diseases in adulthood, such as STIs, it does not follow that circumcision must be performed in infancy. If that were the case, the expensive African programs for mass circumcision of adults as a tactic against heterosexually acquired HIV would be pointless. Despite mounting concern that these programs are less effective and more risky than commonly believed,20 advocates still consider circumcision as a means of reducing the risk of HIV and other STIs to be no less effective in adulthood as in childhood. That being so, why do their arguments for circumcision in developed countries such as the United States and Australia focus on circumcision of infants? I have argued that the answer to this question leads us into an ethical and logical void: The preference for circumcising infants has little to do with the greater efficacy of the intervention in early life, and almost everything to do with its mechanics. Adult men are usually reluctant to be circumcised and are not readily coerced; infants and children have less power to resist and can easily be compelled to submit. Because they are incapable of saying no, children are a softer target. The notion of infancy as the “best time to circumcise” is based on the assumption that prophylactic circumcision is desirable for all and that it will be necessary at some point: If later, the argument goes, why not do it now and get it over with (Wallerstein, 1980)? But if prophylactic circumcision is neither desirable nor necessary, and if unnecessary surgery is “bad” surgery (Begg, 1953, p. 604), the only appropriate times to circumcise are when it is clinically necessary to address a problem that has not responded to medical treatment; or, when a competent male elects the operation for himself and gives his informed consent.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding

The author(s) received no financial support for the research and/or authorship of this article.