Introduction Non-therapeutic circumcision (NTC) raises complex ethical questions, evoking strongly opposing views.¹ British Medical Association (BMA) guidance suggests that it is ethical as long as: both parents give consent; it is performed competently; and it is in the child’s best interests.² Regarding best interests, the BMA emphasises that parental preference alone is insufficient; a number of factors including the patient’s psychosocial needs and cultural background must be assessed.² UK case law suggests that written consent from both parents is required. We sought to determine the extent to which these standards were being met.

Methods We reviewed records of children undergoing NTC between 1/04/2014–1/04/2015, noting demographics, co-morbidity and complications. Notes were reviewed for discussions of risk and the child’s best interests. Consent forms were reviewed for intended benefits, risks and the presence of both parental signatures. All data were anonymised.

Results

• Nine patients were identified; age range 1.5–17 years.

• All received general anaesthesia. Co-morbidity included complex congenital cardiac disease, haemophilia and propionic acidaemia.

• No complications were identified.

• There was no evidence, in any case, of discussions evaluating the interests of the child, beyond suggesting parental preference or religion as the justification for surgery.

• Risks of serious anaesthetic complications were documented in only one case (a child with a univentricular circulation); the parents accepted these risks and the operation proceeded.

• Consent forms described intended benefits as “removal of foreskin”, “religious circumcision”, or left blank. Risks included bleeding, infection and meatal injury. Only one form had the signatures of both parents.

Discussion Our results suggest that the ethical standards set by the BMA are not being met. This may reflect ignorance of the guidance, reluctance to question parental preference, or poor documentation. We suggest all cases be discussed in a multidisciplinary team meeting including the referring medical team, surgeon and anaesthetist. We also propose the introduction of a procedure-specific consent form that would require the consent from both parents and assessment of the child’s best interests to be documented.

References

1. Sanne B. The ethics of infant male circumcision. J Med Ethics 2013;39:418–420

2. BMA. The law and ethics of male circumcision. J Med Ethics 2004;30:259–63