Online First articles may not be available until 09:00 (UK time) Friday.

Press releases Saturday 8 December 2007

Please remember to credit the BMJ as source when publicising an article and to tell your readers that they can read its full text on the journal's web site (http://bmj.com).

(1) Is infant male circumcision an abuse of the rights of the child?
(2) Concept of patients' charters "inadequate"

(1) Is infant male circumcision an abuse of the rights of the child?
(Head to Head: Is infant male circumcision an abuse of the rights of the child?)
Yes
No
(Clinical review: Medical aspects of male circumcision)
Medical aspects of male circumcision

Circumcision is one of the commonest surgical procedures performed on males. Opponents argue that infant circumcision can cause both physical and psychological harm, while recent evidence shows that circumcision is medically beneficial. Two doctors debate the issue in this week's BMJ.

There is now rarely a therapeutic indication for infant circumcision, yet ritual (non-therapeutic) male circumcision continues unchecked throughout the world, long after female circumcision, facial scarification, and other ritual forms of infant abuse have been made illegal, writes Geoff Hinchley, a consultant at Barnet & Chase Farm NHS Trust.

The law and principles pertaining to child protection should apply equally to both sexes, so why do society and the medical profession collude with this unnecessary mutilating practise, he asks?

In addition to religious justification, there have been many spurious and now unsupported claims for circumcision including the prevention of penile cancer, masturbation, blindness, and insanity, most of which relate to adult sexual behaviour and not to the genital anatomy or best interest of a child, he adds.

There may be a case that male circumcision reduces HIV risk in sexually active adults, however the decision on whether an individual wishes to have this procedure should be left until they are old enough to make their own informed health care choices.

Male genital mutilation is not a risk-free procedure, he adds. Far from being a harmless traditional practice, circumcision damages young boys.

And in terms of legal protection, he argues that both the US and the UK legal systems discriminate between the sexes when it comes to protecting boys and girls from damaging ritual genital mutilation.

The unpalatable truth is that logic and the rights of the child play little part in determining the acceptability of male genital mutilation in our society, he writes. The profession needs to recognise this and champion the argument on behalf of boys that was so successful for girls.

But Kirsten Patrick of the BMJ argues that, if competently performed, circumcision carries little risk and cannot be compared with female circumcision.

Although any surgical operation can be painful and do harm, the pain of circumcision, if done under local anaesthesia, is comparable to that from an injection for immunisation, she writes.

In terms of evidence of benefit, male circumcision has been associated with a reduced risk of sexually transmitted infections, such as human papilloma virus, chancroid and syphilis. Robust research has also shown that circumcision can reduce the spread of HIV.

And although the complication rate for infant circumcision is essentially unknown (because most operations are unregistered) data suggest that it is between 0.2% and 3%, with most complications being minor. Furthermore, she says, no robust research exists examining the long term psychological effects of male infant circumcision.

Despite the fact that no medical body advocates routine male infant circumcision, most agree that it is safe and acceptable and recommend that the procedure is carried out by a competent operator using adequate anaesthesia.

Male circumcision is not illegal anywhere in the world. It is a choice that parents will make on behalf of their male children, for cultural or other reasons, and regulating its provision is the wisest course of action, she concludes.

An accompanying clinical review concludes that medical indications for male circumcision in both childhood and adulthood are rare, but that complications can be drastic.

Contacts:
Geoff Hinchley, Accident and Emergency Consultant, Barnet & Chase Farm NHS Trust, Enfield, Middlesex, UK
Email: geoff.hinchley@bcf.nhs.uk  
Kirsten Patrick, former Roger Robinson Editorial Registrar, British Medical Journal, London, UK, via BMA Press Office
Email: edickinson@bmj.com  

(2) Concept of patients' charters "inadequate"
(Patients' charters and health responsibilities)
http://www.bmj.com/cgi/content/short/335/7631/1187

The concept of patients' charters is inadequate and should be replaced with charters of health responsibilities, argues an expert in this week's BMJ.

But even these raise ethical tensions, says Harald Schmidt, a research associate at LSE Health.

The British Medical Association (BMA) recently called for a charter setting out the responsibilities patients have within the National Health Service and what patients can expect from the NHS.

Although it lacked detail, it raised questions about the scope, specificity, and status of such a charter, says Schmidt. So he assessed how health responsibility initiatives in three countries have dealt with these questions and looks at the ethical tensions raised.

He examined the 2005 Scottish NHS' patients' charter: The NHS and You; book V of the 1988 German Sozialgesetzbuch (social security code), revised in 2007; and the Medicaid member agreement, implemented in West Virginia, United States, in 2007.

These documents all apply to publicly funded health programmes but set out responsibilities with varying degrees of specificity, legal status, and enforceability.

The documents all contain explicit health maintenance obligations, such as "Look after your own health and have a healthy lifestyle" (Scottish charter) and "I will do my best to stay healthy" (Medicaid agreement).

But Schmidt warns that, while it is easy to make appeals not to risk health, it is far more complicated to decide whether and to what extent people should be held responsible when things go wrong, especially when expensive treatment is required.

He urges clarity about such decisions, especially for documents with a binding status.

The documents also emphasise obligations to contribute to fair and efficient use of healthcare resources, but these may give rise to several problems, he adds.

For example, appeals to "only use emergency services in a real emergency" may lead people to not request treatment when they need it, or with delay, which may result in poorer overall health and higher costs for the healthcare system.

Similarly, emphasising the need to keep (or cancel) appointments may be unfair for patients who may have good reasons for missing appointments.

With rising healthcare costs, higher burdens of chronic diseases, and increasing evidence about the contribution of genetic and behavioural factors to disease, the issue of personal responsibility for health is here to stay, says Schmidt. There have already been concerns about the decision of some primary care trusts to require, for example, patients to lose weight or stop smoking before routine surgery.

The BMA's proposal for a health responsibility charter, and similar initiatives towards spelling out "rights and responsibilities" as part of Lord Darzi's current review of the NHS, offer unique opportunities to clarify which types of responsibilities are compatible with the ethos of the NHS, and which ones are not, he concludes.

Contact:
Harald Schmidt, Research Associate at LSE Health and Assistant Director, Nuffield Council on Bioethics, London, UK [please note: the views expressed in the article are the authors alone and must not be attributed to the Council] 
Email: H.T.Schmidt@lse.ac.uk 

FOR ACCREDITED JOURNALISTS

Embargoed press releases and articles are available from:

Public Affairs Division, BMA House, Tavistock Square London WC1H 9JR

(contact: pressoffice@bma.org.uk)

and from:

the EurekAlert website, run by the American Association for the Advancement of Science (http://www.eurekalert.org)