“In med school, I was able to stand assisting on two mutilations, but the severe terror and excruciating pain [of the baby] and the residents’ flippant and jocular attitudes turned my guts inside out. Since that point, I [have] refused any further circumcision ‘invitations’ to perform or assist.”
Maram Hakim, M.D.

Conscientious Objection Resources

Conscientious Objection to Non-Therapeutic Circumcision

Introduction

A growing number of medical providers of all specialties in North America and elsewhere are declining – even refusing – to be involved in non-therapeutic, cultural genital reduction surgeries upon minors. And the fact that non-therapeutic genital cutting of North American boys offends human rights – and is thus a suitable cause for requesting conscientious objector (C/O) status – has not gone unnoticed by the medical community:

“There are now substantial established campaigns against non-therapeutic, non-consensual circumcision of boys and growing support to end it, particularly within the medical community.”[1]

Doctors Opposing Circumcision has provided free legal and bioethics advice to conscientious objectors for many years, including nurses and nursing students, medical students, residents, and physicians.

The topic of C/O status in medical care is complicated by its more familiar application to abortion, reproduction, and end-of-life issues. The politics of these has produced a body of law allowing (or forbidding) medical personnel from asserting an objection to certain procedures on religious or ethical grounds. Some laws are federal and uniform; others are highly variable from state-to-state. None specifically grant a right to refuse to perform circumcisions, but those granting a general right to conscience may be employed for that purpose.

Non-therapeutic circumcision provides an easily arguable and valid case for conscientious objection, even in states without specific legal protections for conscientious objectors, for the simple reasons that:

  1. Circumcision violates all five principles of modern bioethics, and many human rights principles.
  2. Circumcision endangers healthy minors who are in no need of genital surgery.
  3. Circumcision is medically unnecessary since the claimed (and debatable) prophylaxis is easily provided by less intrusive, more conservative means.
  4. Circumcision is a culturally driven practice, not medically-indicated, therapeutic, evidence-based care.[2-4]

The scope of conscientious objection is broad, touching as it does on law, bioethics, religion, and culture. We discuss here only the principles as they apply to non-therapeutic genital surgeries upon minors. This page is intended primarily as a practical guide to conscientious objection and to managing the push-back a health care professional is likely to face when questioning non-therapeutic surgeries to minors.

Strategy

The overriding concern in C/O cases is the lack of negotiating power and leverage of a medical or nursing student, or even practicing providers. Thus the strategy is to convince your supervisors, using careful diplomacy, of the seriousness of your beliefs.

Here is the strategy we advise:

  • Do some initial research to see whether there is a law in the jurisdiction in which you plan to practice that gives an unequivocal right to assert C/O status.
  • Is your family religious? Fortunately, North Americans are obliged to be very careful to respect individual religious beliefs. Most religions have general principles that can be asserted in opposition to unnecessary, unwanted, non-therapeutic cutting of a child. Even if you are an atheist or agnostic, you may be able to assert your personal ethical beliefs, though this varies by state and by institution. A claim of religious belief, no matter how recently acquired, is much easier to assert and sustain than one based in ethics (and is difficult to disprove.)
  • Do NOT announce your intention to be a C/O prior to or within an application to a residency or nursing program or other admission process, if you can avoid it. But DO make some quiet inquiries into how the institution has handled such cases in the past.
  • Do NOT announce to your residency program director or your advisor that you have consulted a lawyer. Sad to say, there is no love lost between lawyers and medical providers. Signaling that you might pursue your C/O status using the courts is unhelpful. It could even be deadly to your career and would, in any case, likely be unnecessary.
  • Have you signed, or been presented with, a contract to provide ‘medical care’? One argument that we have found helpful is to assert that circumcision stands outside the scope of ‘medical care;’ it is culturally driven. In fact, for millennia circumcision was only cultural. It was adopted by Anglophone doctors in the late 19th century, before the discovery of germ theory, for puritanical reasons, a fact easily researched. You have no contractual obligation, whether written or implied, to provide culturally driven services. This is especially true for genital reduction surgeries upon healthy minors merely at parental request, without demonstrated therapeutic need.
  • Infant circumcision is essentially micro-surgery, on a tiny structure only a few centimeters long. Tiny mistakes will loom large when the organ grows to 20 times its infant mass. Some states allow a young man to sue for his unnecessary circumcision after age 18, for a period of a year or two, regardless of the result. At least one young man has already been successful in such a case.[5] Do you need that risk so early in your career?
  • Residents often face a circumcision quota (itself a violation of bioethics since this can lead to hasty and coercive consents). Our advice – and it has worked in the past – is to offer to trade with other residents for another intrusive procedure, or for some less-than-desirable task. This offer insures that you are not seen as a slacker who pushes work off onto others.
  • Be aware that performing circumcisions is not required by the Accreditation Council for Graduate Medical Education (ACGME) in order to complete residency training in family medicine, pediatrics, or obstetrics. It is required for urology, but you may wish to limit your experience only to those circumcisions that are medically necessary.
  • The Joint Commission for the Accreditation of Hospital Organizations (JCAHO), the agency that accredits hospitals, requires that facilities have a process that allows staff, patients, and families to address ethical issues or issues prone to conflict.  A hospital’s Human Resources department should have a policy and procedure in place relevant to the needs of staff asserting conscientious objection to non-therapeutic circumcision.

Doctors Opposing Circumcision is available to provide free legal advice to any medical professional struggling with whether or how to assert conscientious objection status for circumcision. 206-465-6636, 9-5 Pacific Time, daily.

References

1. International NGO Council on Violence against Children. Violating children’s rights: harmful practices based on tradition, culture, religion or superstition. Oct 2012. p. 21-22.
2. Waldeck SE. Social norm theory and male circumcision: why parents circumcise. Am J Bioeth. 2003;3(2):56-7.
3. Muller AJ. To cut or not to cut? Personal factors influence primary care physicians’ position on elective newborn circumcision. J Mens Health. 2010;7(3):227-232.
4. Sarajlic E. Can culture justify infant circumcision? Res Publica. 2014;20:327-343.
5. Circumcised – Sues and wins. YouTube website. Uploaded 19 Apr 2009.

Resources

Berlinger N. Conscience clauses, health care providers, and parents. In: Crowley M, ed. From birth to death and bench to clinic: The Hastings Center Bioethics Briefing Book for journalists, policymakers, and campaigns. Garrison (NY): The Hastings Center; 2008. p. 35-40. Discussion of conscientious objection from the perspective of both provider and patient.

Bradley I. Conscientious objection in medicine: a moral dilemma. The NYU Langone Online Journal of Medicine. Clinical Correlations website. 28 May 2009. Discussion of the modern political trend toward protecting the provider’s religious beliefs.

Lachman VD. Conscientious objection in nursing: definition and criteria for acceptance. Medsurg Nurs. 2014;23(3):196-8.

Pate J. Do medical students have to assist in circumcisions? James Pate MD website. 10 Apr 2012.

Savulescu J. Conscientious objection in medicine. BMJ. 2006;332(7536):294-7. A troubling discussion that argues for limiting the ability of medical providers to refuse care, suggesting such a person should not go into medicine. A good source, however, for the arguments a C/O to circumcision is likely to face.

Wicclair MR. Conscientious objection in health care. New York: Cambridge University Press; 2011. Comprehensive ethical analysis of conscientious objection in the areas of medicine, nursing, and pharmacy, including students.

Doctors Opposing Circumcision: Pamphlet on Conscientious Objection

Nurses for the Rights of the Child: Pamphlet on Conscientious Objection

Nurses for the Rights of the Child: Conscientious Objection information page

Published April 2016

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