Welcome to Ethics Consult -- an opportunity to discuss, debate (respectfully), and learn together. We select an ethical dilemma from a true, but anonymized, patient care case, and then we provide an expert's commentary.
Last week, you voted on the ethics of performing genital cutting on a young woman.
Should the clinic doctors agree to perform this "female circumcision" to reduce the risk of harm that may befall her in Ethiopia?
Yes: 36%
No: 64%
Is it ethical to refuse to perform the procedure under these circumstances?
Yes: 77%
No: 23%
And now, bioethicist Jacob M. Appel, MD, JD, weighs in with an excerpt adapted from his book, .
Female genital cutting (FGC) has never been part of the Western tradition, and various efforts have been made to stamp out the practice in Africa and Asia, dating back at least as far as missionary John Arthur and the Church of Scotland's war against the practice in Kenya in the early 1930s.
Critics refer to the procedure as "female genital mutilation" and cite the sexual and medical consequences, although significant disagreement exists over the safety of the operation. Children, of course, cannot meaningfully consent to it.
Yet not all Westerners condemn female circumcision. Some anthropologists view the effort to eradicate the procedure as a form of cultural imperialism.
It is also worth noting that there exists a movement for the elimination of male circumcision on similar grounds, relating to the denial of autonomy and loss of sexual satisfaction, although these "intactivist" efforts are far less widespread. In 2012, a regional court in Germany classified male circumcision as child abuse, but this verdict was later overruled by the national legislature.
The U.S. formally banned the practice in minors in 1996, and 27 states also have laws criminalizing FGC. Even so, in 2000, the African Women's Health Center at Harvard's Brigham and Women's Hospital in Boston estimated that about 228,000 American women have either undergone the procedure or are at risk of having it done. Some families of African and Middle Eastern origin continue to take "circumcision vacations" back in their native countries, or, less frequently, bring elders and midwives to the U.S. to perform the surgery in secret.
While criminal charges have occurred in the U.S. -- most prominently, the prosecution of Khalid Adem for cutting his 2-year-old daughter's genitals with scissors -- they have been relatively infrequent. In 2017, Jumana Nagarwala of Michigan was charged with engaging in the practice, but the case was dismissed when a federal judge ruled the law unconstitutional in November 2018.
Complicating our hypothetical case is the young woman's plan to move back to Ethiopia. If one accepts her explanation that she cannot marry there without having the procedure performed, and that she will have it done there if it can't happen here -- both of which are likely true -- her personal welfare might actually be served by FGC. However, engaging in the practice furthers the tradition and will continue to place other families in a similarly taxing position.
One might reframe the scenario this way: There are some things that physicians (or people more generally) ought never to do. There are other things that physicians (or people) may do only under distinctive and extenuating circumstances. Our hypothetical case asks one to decide which of these principles applies to female genital cutting.
Jacob M. Appel, MD, JD, is director of ethics education in psychiatry and a member of the institutional review board at the Icahn School of Medicine at Mount Sinai in New York City. He holds an MD from Columbia University, a JD from Harvard Law School, and a bioethics MA from Albany Medical College.
And check out some of our past Ethics Consult cases:
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