Ok, let me roll up my sleeves and dissect Tony's remarks:
Intact America ran an open letter, as an advertisement, in yesterday's Washington Post urging the American Academy of Pediatrics not to recommend that American parents circumcise their infant sons as a strategy against HIV. [Full disclosure: I attended an event hosted by the organization and interact with some of its representatives because I support its cause.] It's a logical request, based on the necessary combination of science and ethics. A pro-circumcision advocate, Jake Waskett¹,Tony includes a lengthy footnote at this point, justifying his assumption. I'll omit it, because he's correctly guessed my name. It's a shame that he mischaracterises me as a "pro-circumcision advocate", though (I'm pro-parental choice, not pro-circumcision).
has attempted a deconstruction of the letter, labeling it "propaganda"."Labelling" seems a curious choice of word, implying that the choice of term is dubious. Propaganda is defined as "The systematic propagation of a doctrine or cause or of information reflecting the views and interests of those advocating such a doctrine or cause." Thus, it seems a perfectly appropriate choice of term for an advertisement created by an anti-circumcision organisation for the explicit purpose of promoting their cause to the AAP.
His support for that charge is preposterous, as any approach advocating the circumcision of healthy infant males must inevitably be, but his critique fails because he ignores the central issue involved. After a brief introduction, complete with an absurd assumption about Intact America's motives, Waskett quotes the opening paragraph:(Quotation omitted. I think we can regard this as "noise"...)
I agree with this, [ie., IA's opening paragraph] although I'm not a fan of appeals to authority. As should be evident with the apparent intention of the CDC to recommend infant circumcision, it only takes one ill-conceived recommendation to distract from the core issue.This last sentence is utterly incomprehensible.
Despite my misgivings, Intact America structures the argument correctly because it identifies that core: ethics demand not imposing medically unnecessary surgery on normal, healthy children, regardless of gender or potential benefits.Tony is, of course, free to subscribe to whatever system of ethics he so chooses. However, to my mind he is setting an extraordinary requirement: that an intervention should not merely be medically beneficial, but must actually be necessary. If applied consistently, such a standard would mean, for example, that vaccinations are unacceptable, since they are rarely necessary.
Waskett assesses this with an odd bit of snark about people inventing fireNot really "odd". IA are essentially arguing that medical organisations shouldn't recommend circumcision because no medical organisations have done so to date. If you apply the same reasoning to the invention of fire, you see how absurd it is.
before issuing a parenthetical aside suggesting that the national medical bodies of African nations now implementing mass circumcision programs implies approval. Perhaps this is the case, which circles back to my reservation about an appeal to authority. But assuming it is not a point of fact. Still, if he's granted the point, what does this prove about Intact America's ethical argument?IA offer three reasons why (according to them) it is unethical: unnecessary, potentially risky, and not recommended by major medical organisations. As I point out, the last is an extremely weak argument in the context of what the AAP may recommend. I agree with Tony, to some extent, that it is also an appeal to authority.
The risk of female-to-male HIV transmission through vaginal intercourse is a significant problem in Africa. In America HIV transmission risk through sex overwhelmingly involves male-to-male transmission, from which the (voluntary) circumcision of (adult) males has shown no statistically significant reduction.Tony's words are somewhat misleading here. There haven't been any controlled trials of voluntary circumcision in MSM yet. The American studies to date have mostly compared previously (and probably neonatally) circumcised men with uncircumcised men. Some studies have shown a statistically significant reduction, but others have not.
Even if this wasn't the case, the ethical issue of applying scientific research to healthy children through surgery centers on infant circumcision, not infant circumcision. That's the point Waskett ignores. His defense:(Quotation omitted.)
(Apparently in relation to my remark that risks need to be weighed against the benefits) No, these risks need to be weighed against the need, or rather, the lack of need. The ethics of proxy consent require parents to choose a balance between the most effective and least invasive solution to remedy their child's malady. But there is no malady when the boy is healthy.As Tony correctly observes, the situation we're discussing is not one in which there is an immediately pressing need for therapeutic intervention, hence the "most effective and least invasive" criteria for choosing that intervention do not apply. Instead, the situation involves a healthy child, much as with vaccinations. And as with vaccinations, we weigh the risks (adverse reaction) against the future benefits (reduction of risk of disease). Tony is of course free to apply his own ethical standard, but he should not be surprised that others choose not to follow him.
Setting the ability to chase potential benefits as the ethical standard opens the range of allegedly valid parental interventions to include any number of surgeries we recognize as offensive. The science becomes ungrounded by any concern for the individual child as an individual.Unfortunately, Tony hasn't identified any of these "surgeries we recognize as offensive" that are valid when benefits and risks are properly weighed. I would be interested to learn of any that he - or anyone else - can think of.
Invoking the topic of vaccinations does not change this evaluation. There are similarities between circumcision and vaccination, based on potential benefits. However, the difference rests on how the problems the interventions are meant to prevent occur. For example, becoming infected with measles requires no effort other than participation in society, while acquiring HIV from an HIV+ female through vaginal intercourse requires a very specific action, an action not undertaken by infants. Comparing the two solutions as comparable for parental consent fails.This is a nonsensical argument: it is absurd to analyse the issue as though children never grow up. Peter Pan is fiction. Children grow up to become adults, and yes, that includes having sex.
Add to this the fact that parents treat the same maladies circumcision is supposed to prevent with less invasive, non-surgical methods when they affect their daughters, and Waskett's argument misses the ethical case against infant circumcision because he's making the case for circumcision devoid of context and ethics. That's a case that works only if it's a voluntary decision by the adult male himself.This paragraph makes no sense.
Next, Intact America requests that the AAP defend the ethics against infant circumcision rather than considering a revision in favor of the surgery since science necessarily involves ethics when applied to a person's body, particularly via proxy consent. Waskett calls this request "bizarre," despite having failed thus far to address the ethical argument made by Intact America.If Tony had been paying attention, he would have noticed that I actually identified the three reasons why IA claimed that circumcision was unethical, and addressed each in turn.
[Regarding my statement that the sums saved in disease prevention are probably comparable to those spend on circumcision] Waskett's claim is based on speculation. Perhaps his analysis is correct, but he does not provide proof for his assumption here. We have statistics from other western nations demonstrating the incidence rates for the diseases to which he refers. Since we can analyze circumcision on these terms, "no doubt" is insufficientSeveral studies have been published that have compared the costs of circumcision with that of non-circumcision. For example, Schoen et al. The exact findings have varied a little from study to study, but most have shown that, from a cost point of view, the figures are comparable.
(At this point I'll skip a paragraph, since it basically consists of Tony repeating his claims about what is and is not justified. Since this is clearly his opinion, it seems to require little response from me.)
Waskett seems to think that Intact America ignores the randomized controlled trials showing risk reduction in female-to-male HIV transmission from voluntary adult circumcision. The letter noted this fact in an earlier paragraph. Still, as I read the letter, Intact America is not making an argument about epidemiology. Rather, it is making an argument about populations and risk factors.As a reminder, here is what IA claim: "Doctors have a responsibility to tell parents the truth: circumcision does not prevent disease. Most European nations, with circumcision rates near zero, have lower HIV/AIDS rates than the United States."
As I read that, the second sentence seems to be presented as evidence for the first. If that is so, IA appear to be saying that the most definitive evidence can be found in between-country comparisons.
The risk factors among America's population are similar to those of European nations, not African nations. Our risk is male-to-male transmission and shared needles during IV drug use.If Tony is confident in his assertions, perhaps he will volunteer to have heterosexual intercourse with an HIV+ woman. Probably not, I suspect, because of course that's a risk anywhere. The main difference, of course, is that the probability of exposure changes dramatically. Put bluntly, if you sleep with a person then your risk of acquiring HIV depends on the probability that they are HIV+.
Circumcision protects against neither.I wouldn't personally make such an assertion with any confidence.
Is that complete proof that infant circumcision in America, unlike the randomized trials involving adult volunteers in Africa, is irrelevant to the United States? No, and I don't think Intact America is suggesting otherwise. It is simply working from the central fact,Correction: opinion.
which is that it is unethical to circumcise healthy infant males - who are not sexually active - to prevent a disease for which most of them will face minimal lifetime risk and for which less invasive, more effective prevention methods exist. Europe is an appropriate anecdotal case study that (infant) circumcision is not necessary to achieve the results health officials desire.I believe that Tony is going beyond a generous interpretation of IA's words here. IA clearly state that "circumcision does not prevent disease". That's not a statement in the context of ethics. It's in the context of science: it poses a testable hypothesis.
The complications of circumcision affect individuals. Those individual have rights. We recognize this for female minors, legislating against parental proxy consent for medically unnecessary genital surgery on daughters for any reason. The ethical argument against infant male circumcision involves the equal rights concept that the same protection should be applied to males. Waskett hasn't yet made a coherent case for denying these rights to male minors.It is not meaningful to compare female genital cutting to circumcision. Female genital cutting is a net harm, with no known medical benefits, immediate risks, and a considerable chance of permanent harm. Society passes laws to protect the vulnerable from harm, and so it makes sense to protect children from female genital cutting. But - applying the same principle - it doesn't make sense to legislate against circumcision, because there is no net harm. Most reasonable people, weighing the risks and benefits, come to the conclusion that it is neutral or beneficial.
(Tony's final paragraph omitted, as it is essentially repetition of his arguments.)