Short-Changing Babies — A Presentation for the Perinatal Quality Collaborative of North Carolina (PQCNC)

This article was a prepared for a Medical Forum of the University of North Carolina’s Perinatal Quality Collaborative of North Carolina (PQCNC) in August 2010.

When our first son was born, my husband and I never discussed circumcision before the birth – not with my OB-GYN, not with my pediatrician, and not with each other. It just never came up. The day after the birth, a friendly physician came into and told us they needed our signatures in order to perform the circumcision. I’m sure he asked whether we wanted our son circumcised, but there was no discussion, and it has always seemed to me that circumcision was considered routine and that we were expected to want our son to be circumcised. Regardless of whether there are logical medical reasons behind it, this feeling of expected consent implies that this is what is medically best for our child. We didn’t think much more about it until we discussed circumcision with some friends who hadn’t thought much about it before circumcising their son. We expressed regret that we hadn’t at least thought more about it before consenting to have Seamus circumcised, and my girlfriend was bothered enough by this sentiment that she didn’t want to talk any more about it. What’s done is done was the basic conclusion.

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More than six years later, our second son, Kieran, was born at the same hospital. The day after Kieran was born, the doctor who came to check on me asked whether we would be having Seamus circumcised. We had talked about it but still hadn’t decided. We leaned toward circumcision, if for no other reason than our two sons would look the same ‘down there.’ Fortunately, our doctor called us on this ‘easy way out’ and engaged us in the lengthy and informed discussion we needed. She explained that circumcision had no proven medical benefits, except perhaps for a slightly lower HIV risk in third-world countries with high HIV incidence. Furthermore, an uncircumcised boy was no more difficult to clean, if simply cleaned in the same manner as a circumcised boy.

After we decided not to circumcise Kieran, I was working on a newspaper article regarding our recent personal experience with the circumcision issue and, as I result, I became even more informed. Had I not done the research for the article, I would never have known that currently the major medical societies in the USA, Britain, Canada, Australia and New Zealand do not recommend routine non-therapeutic infant circumcision. I was disturbed to find that physicians in "nearly half" of neonatal circumcisions (2006, American Medical Association) "did not discuss the potential medical risks and benefits of elective circumcision prior to delivery... Deferral of discussion until after birth, [and] the fact that many parents' decisions about circumcision are preconceived, contribute to the high rate of elective circumcision.”

In a 1987 study, most American parents chose circumcision due to "concerns about the attitudes of peers and their sons' self concept," rather than medical reasons.

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I think it is a mistake for physicians to wait for their patients to initiate a deeper discussion of their options and their consequences, and a bigger mistake to think that if their patients don’t initiate such discussion they are completely comfortable with the medical decisions they are making or agreeing to. On the contrary, I think that it is a medical doctor’s role to initiate such discussion with his patients. In many cases, probably most cases, the patients don’t even realize there is a discussion that might need initiating. Instead, they presume that their doctor wouldn’t offer an option or suggestion if it wasn’t in their best interest to do so.

I think that physicians, and non-physicians for that matter, presume that certain people -- those with higher degrees for instance, or who have had similar experiences/problems in the past (such as parents who are on their second or third child) -- already know the facts behind most of the medical options presented to them, or if they don’t know the facts they know how to find them on their own. This simply isn’t true. My husband and I have our Ph.D.’s in Chemistry (from UNC), but we aren’t any more familiar with the best chemicals to remove carpet stains or the chemical ingredients on a package of potato chips than anyone else we know.  Why then would we know anything more about routine medical procedures like circumcision than anyone else? Regardless of their education and background, and regardless of all the information now available on the Internet, patients generally do what they think their doctors want them to do. And if their doctor doesn’t initiate discussion, patients will just presume that it is best that they agree to whatever procedure or medication their doctor is suggesting.

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Whether or not it’s true, a lot of people think that the reason such discussion doesn’t happen is because doctors nowadays are under pressure to see so many patients per day that they simply don’t have or take the time to engage their patients and truly question and inform them regarding their medical decisions. Furthermore, the medical business has become such a business that patients are too often seen as paying clients who deserve a significant level of customer service. In other words, their patients should get what they want as long as it doesn’t put the business in more danger of litigation.

My mother is a physician, and I know that like her, you went into medicine because you wanted to help people and to do what is best for them, regardless of business demands, litigation fears, and customer satisfaction. And I have no doubt that by initiating and engaging your patients in a deeper discussion regarding your sincere medical opinions (and those of the American Medical Association and other such organizations), you will only give them more trust in you, as their doctor, and making them more comfortable and happy with their medical care.

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We feel fortunate that our doctor took the time to discuss circumcision with us, rather than just seeking a yes or no answer and then moving on to the next patient on their, no doubt, busy schedule. We have no regrets about the serendipitously conscientious decision we made with our second son.

I think it’s great that you all are taking this initiative to discuss and encourage real discussion between physicians and their patients regarding the facts, and the pros and cons of the options available to them.