American Academy of Pediatrics

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Emblem of the American Academy of Pediatrics


The American Academy of Pediatrics (AAP) currently advises parents on its "Healthy Children" website that "The existing scientific evidence is not sufficient to recommend routine circumcision."[1] Be that as it may, they still say that they "...recommend that the decision to circumcise is one best made by parents in consultation with their pediatrician." While not recommending circumcision, the AAP shirks responsibility by refusing to take a clear stand and state anything more directly negative than saying "the scientific evidence is not sufficient to recommend." The evidence, of which there is not enough for the AAP to come to a concrete conclusion, must apparently still be considered by parents, placing them in the awkward position of doing what the AAP could not do. Many view the AAP's policy as a "cover your ass" move: an awkward attempt shield itself and its members (doctors), from possible future legal repercussions, by distancing them as far as possible from any ethical considerations in the decision of parents to circumcise (while allowing its members to continue profiting from the procedure).

The AAP Briefly Endorses Female Genital Cutting

On April 26, 2010, the AAP changed its long-held stance against female genital cutting. [2] In their report, chiefly authored by Dena Davis, a professor at Cleveland-Marshall College of Law at Cleveland State University,[3] the AAP advised doctors to inform families that the procedure is medically unnecessary and even dangerous.[4] The AAP raised the idea of legalizing a less-severe ritual cutting, which they compared to an ear piercing,[5][6] the reasoning being that female circumcision had symbolic or ceremonial aspects for many parents,[7] and offering a "ritual nick" might dissuade parents that were resolute, from sending their daughters to their home countries,[8] thereby avoiding greater harm.[9] The AAP had deviated from a much more forceful statement published in 1998, which unequivocally condemned FGC in any form.[10]

The Girls Protection Act, which would make it illegal to take a minor outside the U.S. to seek female circumcision, was introduced in Congress on the same day the AAP published its new recommendation. [11] New York Representative Joseph Crowley, one of the bill's sponsors, condemned the AAP's move as "the wrong step forward on how best to protect young women and girls" by creating confusion about the acceptability of FGM in any form.[12] Davis of the AAP countered that such a law would be difficult to enforce.[13]

The AAP's endorsement of a "ritual nick" sparked a backlash[14] which was swift and universally negative. The AAP's recommendation had been perceived by many as a tacit endorsement of the "ritual nick," and an effort to appease parents who threatened to subject their daughters to worse procedures.[15] In short, the AAP was forced to retract its endorsement, and on May 1, Judith Palfrey, President of the AAP, released a statement that read in part, “the AAP does not endorse the practice of offering a ‘clitoral nick’. This minimal pinprick is forbidden under federal law and the AAP does not recommend it to its members”. [16] Palfrey reiterated this stance in an interview with The Lancet, saying “we want to make it clear to the international community we are opposed to any form of female genital cutting, and that includes the ritual nick.” [17] The AAP has since withdrawn the committee's report and is re-writing it completely. [18]

The AAP wrote the following in their 2010 FGC Policy:

The American Academy of Pediatrics policy statement on newborn male circumcision expresses respect for parental decision-making and acknowledges the legitimacy of including cultural, religious, and ethnic traditions when making the choice of whether to surgically alter a male infant's genitals.(119)

AAP Policy Statement on Ritual Genital Cutting of Female Minors (April, 2010). Author: Committee on Bioethics


This was a segue into the following sentence:

But parental rights have limits -- FGC is damaging so it should be disallowed. But maybe we should change the law for the mild alterations.(119)

AAP Policy Statement on Ritual Genital Cutting of Female Minors (April, 2010). Author: Committee on Bioethics


In other words, they were using the fact that MGM is accepted as an argument in favor of "milder" FGM.

The AAP's 1999 Circumcision Policy Statement (and its apparent contradictions with other AAP positions on bioethics)

The AAP asserted in their 1999 Circumcision Policy Statement that parents have a right to decide to circumcise their children based on cultural or religious factors (although they removed any mention of esthetics as a possible parental motivation, despite previous inclusion in their 1989 statement). No further substantiation of this right was offered. Whether or not a medical benefit was required for parents to make this choice was also not addressed.

The following statement appeared in its 1999 Policy Statement:

In the pluralistic society of the United States in which parents are afforded wide authority for determining what constitutes appropriate child-rearing and child welfare, it is legitimate for the parents to take into account cultural, religious, and ethnic traditions, in addition to medical factors, when making this choice.(119)

1999 AAP Circumcision Policy Statement" (re-affirmed 2005)


The above sentence cited Caring for Gravely Ill Children[19] as its source. While this document focuses primarily on sick children and not infants, it does go into much detail on the ethics surrounding autonomy and consent, particularly with respect to patient-centered vs. parent-centered medicine. That document says the following, which the AAP's "hands-off" position on circumcision might contradict:

This patient-centered "best interest" standard, which has been accepted by a broad spectrum of groups and commentators, [n9,n10] emphasizes that children ought to be valued as individuals and protects children in situations involving conflict between what is best for the child and what is best for the family or society.

Caring for Gravely Ill Children (1994)


The AAP 1999 Policy Statement also includes this statement on informed consent:

The process of informed consent obligates the physician to explain any procedure or treatment and to enumerate the risks, benefits, and alternatives for the patient to make an informed choice. For infants and young children who lack the capacity to decide for themselves, a surrogate, generally a parent must make such choice.(118)

1999 AAP Circumcision Policy Statement" (re-affirmed 2005)


The above sentences cited Informed Consent, Parental Permission, and Assent in Pediatric Practice, a policy guide by AAP's Bio-ethics Committee.[20] However, those sentences appear to contradict the document they cited, which says:

Such providers have legal and ethical duties to their child patients to render competent medical care based on what the patient needs, not what someone else expresses. [...] the pediatrician's responsibilities to his or her patient exist independent of parental desires or proxy consent.

AAP Committee on Bioethics - Informed Consent, Parental Permission, and Assent in Pediatric Practice


That document also says:

A patient's reluctance or refusal to assent should also carry considerable weight when the proposed intervention is not essential to his or her welfare and/or can be deferred without substantial risk.

AAP Committee on Bioethics - Informed Consent, Parental Permission, and Assent in Pediatric Practice


The AAP has no official position on whether a baby can refuse a procedure, nor does it specify if crying in pain counts as reluctance or refusal. However, they do write that a patient's discomfort should be taken into account, and that children should have the necessity of a procedure communicated to them.[21] (It might follow that inability to do so means that proceeding with an intervention that could be harmlessly deferred constitutes needless violation of autonomy, or inadequate consent):

Although very young children may be unable to envision the future benefits of treatment that may justify its associated burdens (eg, pain, discomfort, and hospitalization), their perceptions of those burdens should not be ignored.
[...]
Regardless of the child's level of participation in planning care, he or she should be given as much control over the actual treatment as possible.

Caring for Gravely Ill Children (1994)


References

  1. Where We Stand: Circumcision". AAP Official Website. 03/23/2011. http://www.healthychildren.org/English/ages-stages/prenatal/decisions-to-make/pages/Where-We-Stand-Circumcision.aspx
  2. Luscombe, Belinda (2010-05-11). "Has a U.S. Pediatrics Group Condoned Genital Cutting?". Time. http://www.time.com/time/health/article/0,8599,1988434,00.html. Retrieved 2011-09-27. "On April 26, the organization changed its long-held stance on female genital cutting..." 
  3. Luscombe, Belinda (2010-05-11). "Has a U.S. Pediatrics Group Condoned Genital Cutting?". Time. http://www.time.com/time/health/article/0,8599,1988434,00.html. Retrieved 2011-09-27. "...the report's lead author, Dena Davis, a professor at Cleveland-Marshall College of Law at Cleveland State University..." 
  4. Luscombe, Belinda (2010-05-11). "Has a U.S. Pediatrics Group Condoned Genital Cutting?". Time. http://www.time.com/time/health/article/0,8599,1988434,00.html. Retrieved 2011-09-27. "In its new report, the AAP advises doctors to inform families..." 
  5. Luscombe, Belinda (2010-05-11). "Has a U.S. Pediatrics Group Condoned Genital Cutting?". Time. http://www.time.com/time/health/article/0,8599,1988434,00.html. Retrieved 2011-09-27. "...the AAP raises the idea of legalizing a less-severe ritual cutting..." 
  6. MacReady, Norra (2010-07-03). "AAP retracts statement on controversial procedure". The Lancet 376 (9734): 15. doi: 10.1016/S0140-6736(10)61042-2. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)61042-2/fulltext. Retrieved 2011-09-27. "The authors suggested that a “ritual nick,” in which the clitoral skin is pricked or incised, might satisfy these symbolic requirements, and “is no more of an alteration than ear piercing”.". 
  7. MacReady, Norra (2010-07-03). "AAP retracts statement on controversial procedure". The Lancet 376 (9734): 15. doi: 10.1016/S0140-6736(10)61042-2. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)61042-2/fulltext. Retrieved 2011-09-27. "...female circumcision had symbolic or ceremonial aspects.". 
  8. Luscombe, Belinda (2010-05-11). "Has a U.S. Pediatrics Group Condoned Genital Cutting?". Time. http://www.time.com/time/health/article/0,8599,1988434,00.html. Retrieved 2011-09-27. "...to dissuade parents from sending their daughters to be circumcised in their home country..." 
  9. Luscombe, Belinda (2010-05-11). "Has a U.S. Pediatrics Group Condoned Genital Cutting?". Time. http://www.time.com/time/health/article/0,8599,1988434,00.html. Retrieved 2011-09-27. "...a ritual nick as a possible compromise to avoid greater harm..." 
  10. MacReady, Norra (2010-07-03). "AAP retracts statement on controversial procedure". The Lancet 376 (9734): 15. doi: 10.1016/S0140-6736(10)61042-2. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)61042-2/fulltext. Retrieved 2011-09-27. "...the AAP revised a much more forceful statement published in 1998, which unequivocally condemned FGC in any form.". 
  11. Luscombe, Belinda (2010-05-11). "Has a U.S. Pediatrics Group Condoned Genital Cutting?". Time. http://www.time.com/time/health/article/0,8599,1988434,00.html. Retrieved 2011-09-27. "On the same day the AAP published its new recommendation..." 
  12. Luscombe, Belinda (2010-05-11). "Has a U.S. Pediatrics Group Condoned Genital Cutting?". Time. http://www.time.com/time/health/article/0,8599,1988434,00.html. Retrieved 2011-09-27. ""I am sure the academy had only good intentions..."" 
  13. Luscombe, Belinda (2010-05-11). "Has a U.S. Pediatrics Group Condoned Genital Cutting?". Time. http://www.time.com/time/health/article/0,8599,1988434,00.html. Retrieved 2011-09-27. "Davis counters that such a law would be extremely difficult to enforce." 
  14. MacReady, Norra (2010-07-03). "AAP retracts statement on controversial procedure". The Lancet 376 (9734): 15. doi: 10.1016/S0140-6736(10)61042-2. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)61042-2/fulltext. Retrieved 2011-09-27. "The American Academy of Pediatrics (AAP) sparked a backlash...". 
  15. MacReady, Norra (2010-07-03). "AAP retracts statement on controversial procedure". The Lancet 376 (9734): 15. doi: 10.1016/S0140-6736(10)61042-2. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)61042-2/fulltext. Retrieved 2011-09-27. "..was interpreted by many as a tacit endorsement of the ritual nick...". 
  16. MacReady, Norra (2010-07-03). "AAP retracts statement on controversial procedure". The Lancet 376 (9734): 15. doi: 10.1016/S0140-6736(10)61042-2. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)61042-2/fulltext. Retrieved 2011-09-27. "On May 1, Judith Palfrey, President of the AAP, released a statement...". 
  17. MacReady, Norra (2010-07-03). "AAP retracts statement on controversial procedure". The Lancet 376 (9734): 15. doi: 10.1016/S0140-6736(10)61042-2. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)61042-2/fulltext. Retrieved 2011-09-27. "“we want to make it clear to the international community we are opposed to any form of female genital cutting, and that includes the ritual nick.”". 
  18. MacReady, Norra (2010-07-03). "AAP retracts statement on controversial procedure". The Lancet 376 (9734): 15. doi: 10.1016/S0140-6736(10)61042-2. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)61042-2/fulltext. Retrieved 2011-09-27. "The AAP has since withdrawn the committee's report and has rewritten it completely.". 
  19. Fleischman AL, Nolan K, Dubler NN, et al. (1994). "Caring for gravely ill children". Pediatrics: 7. http://pediatrics.aappublications.org/content/94/4/433. Retrieved 2011-10-09. 
  20. Committee on Bioethics (1995-02). "Informed Consent, Parental Permission, and Assent in Pediatric Practice". http://www.cirp.org/library/ethics/AAP/. Retrieved 2011-10-09. 
  21. Fleischman AL, Nolan K, Dubler NN, et al. (1994). "Caring for gravely ill children". Pediatrics: 7. http://pediatrics.aappublications.org/content/94/4/433. Retrieved 2011-10-09. 
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