Irreversible bodily interventions in children.

I n this issue of the Journal of Medical Ethics you can read a minisymposium on circumcision, mainly dealing with the circumcision of male children at an age where they cannot consent, but also touching upon issues of female genital mutilation. When reading the papers I found it strange, but of course not really surprising given its symbolic importance, that we are so worried about interventions on the male penis. Why are we not equally worried about other irreversible bodily and mental interventions to which parents subject their children? I will not dwell on the irreversible mental imprinting, apart from mentioning that upon becoming a father I was amused to find that certain Danish lullabies and children’s rhymes had apparently been stored in my mind for the last 40 years, just waiting to be activated by the sight of a baby. What about other irreversible bodily interventions, however, such as ritual or cultural tattoos and scarification, or ear piercing for earrings? Where is the serious ethical discussion on these issues? Let us take ear piercing of very young girls as our example. This procedure is painful and often performed without anaesthesia or analgesia, and because of the pain it constitutes an immediate harm. It is not without risk of serious complications, mainly infections, which may in severe cases lead to permanent damage to the auricular cartilage with lasting deformity, and it aims at and produces an irreversible bodily change. When performed in very young girls it is not performed for the immediate benefit of the child, but for the benefit of the parents (‘‘she looks so cute lying there in her cot with earrings’’), or to make the child fit in better with the parent’s culture (as far as I know no one have ever claimed that ear piercing had any positive health benefits). For exactly the same reasons that are marshalled against circumcision, ear piercing can therefore not be claimed to be in the immediate best interest of the child, and given the risk of permanent damage it seems prima facie questionable whether it should be within the protected area of parental discretion. We also have to take account of the fact that the child might grow up and reject her parents’ culture in which earrings and by extension ear piercings are positively valued, perhaps later seeing them as instruments of patriarchal oppression, or as irredeemably bourgeois. It is thus by no means certain that the ear piercing will be in the child’s long term best interest, even if there are no complications. Does all this mean that ear piercing should be prohibited until the child is old enough to consent herself? We could try to answer this question very quickly by saying that any irreversible procedure which is not in the child’s best interest and which is harmful and/or carries any risk should be prohibited. That, however, seems much too fast. Parents make numerous decisions that have these characteristics, and it is unclear whether childhood would actually be any better, if they were not allowed to make any. No, just as in the case of circumcision the question of whether ear piercing is allowable must very much depend on the risk and magnitude of permanent harm, both physical and in terms of later conscious rejection of the procedure (it is important to note that a person may later wish that the intervention had not been performed, but not be really bothered about it, so that the amount of harm may be negligible even in cases of later conscious rejection). It is therefore very interesting that the piece of evidence we really need to have in order to be able to assess the status of circumcision is singularly lacking. We simply do not have valid comparative data concerning the effects of early circumcision on adult sexual function and satisfaction. Until such data become available, the circumcision debate cannot be brought to a satisfactory conclusion, and there will always be a lingering suspicion that the sometimes rather strident opposition to circumcision is partly driven by cultural prejudices, dressed up as ethical arguments.