Monday, 26 October 2009

Intact America, part 3

In the ongoing inter-blog discussion about Intact America's advertisement, Tony at RollingDoughnut.com has responded to my response. Tony and I have clearly both spent considerable time thinking about these issues, and I suspect that we will never convince each other of the core issues. Nevertheless, I found his response interesting.

Regarding his mischaracterisation of my position, Tony writes:
I do not accept that I've mischaracterized his position as a pro-circumcision advocate. However, I'll clarify to be as specific as possible. He believes the potential benefits of infant male circumcision outweigh the risks and negatives, a subjective conclusion based on his preferences. Given that he uses his conclusion to encourage parents to circumcise their sons, the difference he states is immaterial.

I find this a rather peculiar statement. I suppose in a sense that any attempt to weigh benefits against risks will have some subjective qualities, and perhaps that can't be avoided altogether. However, as subjective values are meaningless to another person I would hope that most observers try as objective as is reasonably possible. I certainly try; I can only hope that I succeed.

I am uninterested in convincing or encouraging parents to circumcise their sons, and have been careful to avoid making a recommendation either way. Anyone sufficiently interested (not to mention patient) can verify this by working through the many thousands of my public comments over the years - I use the same name everywhere, so it is not difficult to find them via Google. Indeed, I believe that such advocacy would be contrary to my pro-parental choice position: I genuinely believe that parents should make that decision, not me.

Skipping over some content, Tony clarifies an earlier point. He writes:
If an authority cited directly (e.g. AAP) or indirectly (e.g. CDC) changes its position in a way that then conflicts with the original appeal, the appeal to authority may weaken the case for the target audience. It's an ineffective strategy.

My first inclination was to agree, but on reflection I think it would depend on the situation. Consider the following hypothetical scenario:

PERSON A: Circumcision is awful because the AAP don't recommend it.
AAP: [Introduces a recommendation in favour of circumcision]
PERSON A: Oh, the AAP are biased, ignore them.

Here the appeal to authority is utterly invalid. It is quite apparent that it is a sham: the AAP are being presented as an authority merely because the person hopes to gain an advantage by doing so. The person clearly has no integrity, nor any credibility, and can and should be ignored. Now consider this:

PERSON A: Circumcision is awful because the AAP don't recommend it.
AAP: [Introduces a recommendation in favour of circumcision]
PERSON A: Okay, the AAP now recommend it, so it's okay.

In this situation, it seems to me that this is a valid appeal to authority, in that the person is willing to adapt their position once the authority changes theirs.

Regarding Tony's requirement that surgery must be "necessary", which I questioned, Tony writes:
His assessment is close, but too neat for this complicated comparison. That is the requirement I set for proxy consent to surgery. The scenario for vaccinations differs.

I see: Tony applies a different standard for surgery and vaccinations. This doesn't make much sense to me, for several reasons. Firstly, from an admittedly pedantic point of view, is there really that much of a difference? Surgery involves risk. Vaccinations involve risk. Surgery involves cutting the skin. Vaccinations (as delivered by a needle) also involve cutting the skin, albeit in a minor way. So I have to ask, where exactly would you draw the line?

Secondly, does it make sense to create multiple standards? To my mind, no. But I may be biased: I'm trained as an engineer, and when I observe lots of different little rules I see a situation in which there ought to be one, more general rule. Special cases are usually an indication that the general rule needs some more attention. Maybe one shouldn't apply engineering principles to ethics. I don't know, but I can't see any reason why one shouldn't...

In response to my comment that "Children grow up to become adults, and yes, that includes having sex", Tony writes:
Of course, to which I reply as a start: condoms. Condoms are among the many possibilities short of circumcision as an infant available to adult males, including circumcision as an adult, to reduce the risk of HIV transmission.

And from slightly further on:
Assuming voluntary adult circumcision is shown to reduce the risk of all forms of HIV transmission through sex, parents can't know that their sons will be irresponsible and "need" this intervention. It's a speculation that does not need to be made for a child. He can choose it later.

To both points, I agree. Nevertheless, it seems difficult to deny that if it were performed during infancy, circumcision would help to reduce this risk when the child became an adult.
Ultimately the comparison to vaccines must rest on diseases like HIV rather than the other potential benefits used to justify circumcision. They roughly share some of the same characteristics. The comparison fails because, as I wrote, the way in which the diseases spread differ. For most vaccines, it is the most effective and least invasive way to stop the spread of the targeted disease. With comparable diseases, circumcision is neither the most effective or the least invasive method available.

There are differences in the way in which the diseases spread, certainly, but I disagree with Tony that the comparison fails as a result. As far as I can tell, the difference has no bearing on the validity of the comparison in the specific context in which it was made.
There is no need, so "most effective/least invasive" doesn't apply? Jake is begging the question he wants to answer rather than addressing objective facts. He's saying that the standard for surgical intervention on a child should be stricter when the child is sick than when he is healthy. Parents can be more speculative and exploratory with surgery for their healthy (male) children? That's ridiculous. Without objective need for an intervention, proxy consent for surgery can't be valid. With objective need, it can be valid because the child needs some form of decision made and he is incompetent to make that decision.

Here I believe Tony has misunderstood, or at least has not considered the issue with sufficient care. If there is a medical problem to address, then the physician's responsibility is to solve that problem while exposing the patient to the least risk. That's the essence of the "most effective/least invasive" standard. But if there is no medical reason for considering circumcision, then it is meaningless to even consider the "most effective" solution. If circumcision is being considered for non-medical reasons then it is in all probability the only solution to the problem (that being that the child is not circumcised). So it is the wrong standard to apply.

At this point Tony declined to list '"surgeries we recognize as offensive" that are valid when benefits and risks are properly weighed', stating:
I am not citing any particular science or surgeries because that was not my point.

This is a shame. I had hoped that Tony would at least try. I cannot think of any, and my suspicion is that this is because none exist. And if none exist, then Tony's earlier objection that "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" seems a rather empty objection.

Tony continues:
But to his retort, if a study were to find potential health benefits for genital cutting in a study of adult female volunteers, would that be acceptable to apply to healthy female minors? I've had this discussion with Jake previously, so I know he'd have no problem with it if parents subjectively valued the benefits more than the risks. He is wrong. Society would be (correctly) outraged at the suggestion of violating the child's rights in favor of her parents' "rights". Our anti-FGM laws would not be overturned. Those results would never be applied, regardless of the science.

In an ideal world, I wish I could say that anti-FGC laws would indeed be overturned if scientific knowledge changed significantly. However, I'm sorry to say that Tony is probably right in that they wouldn't be. I don't think that this has anything to do with rights, though: it's a simple case of collective prejudice. The notion that FGC is horrific is deeply ingrained into modern, Western society, and it takes an awful lot to dislodge that notion. I know this from personal experience: I have to make a conscious effort to think about FGC objectively, and have to fight the knee-jerk reaction. And I consider myself very open-minded.

On a related note, Tony writes:
That paragraph is clear. We apply different standards to boys and girls. A female minor's risk of UTI is higher than that of a male minor's, yet we do not vigorously seek proof that genital cutting is the answer, nor, as I said above, would we apply it to infant girl if we could find such results. Now replace UTI with cancer. Ethically, we'd have the same approach to girls. Their genitals would be off-limits.

Evidence actually suggests that female genital cutting actually increases the risk of UTI...
Jake establishes a straw man here. I made a statement of fact about HIV transmission in the United States. His rebuttal is that I should be willing to have sex with an HIV+ woman because I state that voluntary, adult circumcision applied to infant males is not what we need. Presumably he means without a condom. Where have I said that unsafe sex - of any kind, with or without a foreskin - is wise? Jake's scenario is a stupid diversion.

Perhaps I should have made my point more clear (or, arguably, made a better point). Let me explain. My words were in response to Tony's statement that "Our risk is male-to-male transmission and shared needles during IV drug use", which seemed to be saying "there is no risk of female-to-male transmission in the US". That isn't true. The absolute risk may be small, but it exists and shouldn't be ignored.

Tony continues:
It is meaningful to compare female genital cutting to male genital cutting because, ethically, they involve the same issue. Unnecessary surgery on a non-consenting individual is wrong.

If you take that last sentence as axiomatic, then you will probably see the two issues as similar (although, presumably, there's no reason to focus on genital surgery in particular). Those of us who adopt a different ethical principle - something like "harmful surgery on a non-consenting individual is wrong" see no problem with circumcision, and a problem with female genital cutting.
America's anti-FGM law makes no exemption for potential benefits or parental opinion.

This is true, and in that respect it does make itself rather inflexible in the face of possible scientific developments in future.
The former is, as Jake points out, not shown by studies. The latter is all that informs infant male circumcision, since an evaluation of potential benefits is opinion absent any objective indication for the child's healthy genitals.

Here Tony is making a mistake. Evaluation of potential benefits should not be dismissed as mere opinion. The literature contains a relatively large amount of data, which can be summarised in the form of objectively quantifiable data.
There is an obvious double standard. Girls may not have their healthy genitals cut for any reason. Boys may have their healthy genitals cut for any reason. That's the valid comparison.

That's not even correct. Try getting a surgeon to perform a glansectomy on a healthy boy. Or castrate him. Or perform any number of other surgeries on his genitals. He or she will refuse. Most such surgeries are a net harm (except when actually needed, in which case the benefits are considerably greater, thus making them a net benefit), and cannot therefore be ethically performed. Circumcision is unusual precisely because it is a surgery which is neutral or (depending who you ask) a net benefit. And that's why the reason for a specific circumcision doesn't really matter.

7 comments:

consult4 said...

So, Jake, can you provide a rational ethical justification for non-therapeutic male infant circumcision--where the PROVEN benefits outweigh the PROVEN harms and losses?

By proven, I mean those scientifically PROVEN.

Hugh7 said...

"If circumcision is being considered for non-medical reasons then it is in all probability the only solution to the problem (that being that the child is not circumcised). So it is the wrong standard to apply."

Exactly how is not being circumcised a "problem" that a doctor needs to address? Jake is trying to transform something in the parent's head into something attaching to the child.

Jake said...

Exactly how is not being circumcised a "problem" that a doctor needs to address? Jake is trying to transform something in the parent's head into something attaching to the child.

What I'm doing is examining the reason why circumcision is being considered in the first place. In the case of therapeutic circumcision, the reason why circumcision is being considered is the desire to solve a medical problem. In the case of non-therapeutic circumcision, the reason is that the parents have chosen circumcision for the child. In the former case, there might be many possible solutions, so it is meaningful to select between them. In the latter, there is typically only one, so no meaningful selection can take place.

consult4 said...

"What I'm doing is examining the reason why circumcision is being considered in the first place. In the case of therapeutic circumcision, the reason why circumcision is being considered is the desire to solve a medical problem."

Here there is a reason--with REASONING.

"In the case of non-therapeutic circumcision, the reason is that the parents have chosen circumcision for the child. In the former case."

Here there is no reason --with REASONING--just irrational excuses.

Jake said...

Here there is no reason --with REASONING--just irrational excuses.

I haven't specified any particular reasoning for the parent's request, because it's not relevant for the purpose of analysing the situation from the doctor's point of view. Furthermore, I think it is more productive to think about general, more abstract issues than a particular line of reasoning.

The fact that I didn't specify a particular line of reasoning, though, doesn't imply that none exists, nor does it imply that such reasoning constitutes an "irrational excuse". I don't see any way to make such a conclusion unless the actual reasoning was known.

Tony said...

My response is here.

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