Medical, religious and social reasons for and against an ancient rite.

This month’s issue of the Journal of Medical Ethics is a special issue devoted entirely to the ethics of infant male circumcision—an elective surgical practice that is currently performed on around a third of the world’s male population. The last time the Journal ran a symposium on this issue was in 2004, and there has been relatively scant discussion of the practice in the ethical literature since then. Three events that took place in the past year have brought the ethics of infant male circumcision back into the global spotlight. First, in April of 2012, controversy erupted after it was reported that a baby had died in New York City after contracting Herpes Simplex virus during the Orthodox Jewish variant of circumcision known as metzitzah b’peh, which involves the oral suction of blood from the infant’s penis following the circumcision procedure. Later that year, the American Academy of Pediatrics (AAP) released a policy statement which suggested that the health benefits of ordinary forms of male circumcision outweigh the risks and costs of the practice. A number of articles have since been published in support and in criticism of the AAP’s report, and the debate continues in these pages, as Steven Svoboda and Robert Van Howe write a critique of the evidentiary basis of the AAP’s report (see page 434), and the AAP Task Force responds (see page 442). Finally, the issue was also in the news in Europe, after a controversial German court decision ruled that the circumcision of male infants amounts to grievous bodily harm, and that the practice violates a child’s right to bodily integrity and to selfdetermination. As legal scholars Merkel and Putzke discuss in this issue (see page 445), the ruling was later accompanied by a new law enshrining the right to perform circumcisions for religious reasons. Much of the debate so far has focused on the medical benefits and risks of circumcision. Yet at least outside of the USA, the great majority of circumcisions are performed as religious rites in Muslim or Jewish families. For this reason, and in light of the German legal decisions, our call for papers asked authors to also consider the non-medical goods and harms associated with the practice, and its religious and cultural justifications. Joseph Mazor’s feature article takes up that challenge in these pages, (see page 421, Editor’s choice). While he argues that the risks and benefits of male circumcision are finely balanced in non-religious families, he argues that the practice is justified in religious families by its role in integrating the infant into the religious community. His arguments are challenged not chiefly on principled grounds but primarily on empirical grounds in two commissioned commentaries. David Benatar, one author of perhaps the bestknown moral defence of circumcision argues that Mazor overstates the medical downsides of circumcision (see page 431), while David Lang argues that Mazor understates these risks (see page 429). Mazor, in his response, concludes that parental choices should prevail as long as reasonable disagreements persist over the balance of scientific evidence on benefits and risks. Matthew Johnson also argues in favour of the idea that religious justifications of circumcision should be given some weight (see page 450). However, he cautions that the use of such justifications can make religious bodies responsible for any ill-consequences that may result from the operation, and he argues that men who believe that they have been harmed by their circumcision should be able to seek damages against their religious community. On the other side of the aisle, several authors in this month’s issue argue more directly for the impermissibility of male infant circumcision. Medical historian Robert Darby argues that circumcision violates a child’s ‘right to an open future’ (see page 463), while paediatrician Robert Van Howe argues that we ought to abandon the idea that parents have a right to make decisions regarding their children’s welfare in cases where these decisions conflict with the rights and/or best interests of the child (see page 475). Hanoch Ben-Yami takes a different approach to the evidence and to religious justifications in his brief article (see page 459). Although he concludes that circumcision is on balance a ‘primitive’ and harmful practice, he argues in favour of a policy of harm minimisation rather than an outright ban. In Ben-Yami’s view, outlawing circumcision might engender racial and religious disharmony, and might also make the practice less safe, resulting in an overall greater level of harm to children and to society at large. Bioethicist Dena Davis also argues that harm reduction measures should be employed. But she points out, controversially, that similar measures might also make certain forms of female genital cutting ethically acceptable and justifiable on religious grounds, and she proposes that we re-open the discussion on female genital cutting (see page 456). It is our hope that by publishing a diverse range of views on controversial subjects such as these, the ethical debate can be driven forward—not only on the medical justifications of circumcision, but on the cultural, political and religious justifications of one of the most common, yet most contentious medical procedures.