May 2010 – Rolling Doughnut

The Facts, Although Interesting, Are Irrelevant

When I wrote about the American Academy of Pediatrics’ revised policy statement on ritual genital cutting of female minors, I sensed some misunderstanding of what the policy says. Then the story hit the New York Times, among many outlets covering it, confirming what I suspected.

In a controversial change to a longstanding policy concerning the practice of female circumcision in some African and Asian cultures, the American Academy of Pediatrics is suggesting that American doctors be given permission to perform a ceremonial pinprick or “nick” on girls from these cultures if it would keep their families from sending them overseas for the full circumcision.

Saying that the AAP now supports female genital cutting grabs attention, but it’s not an accurate summary of the policy statement. The AAP’s conclusion:

The American Academy of Pediatrics:

Opposes all forms of FGC that pose risks of physical or psychological harm.

Encourages its members to become informed about FGC and its complications and to be able to recognize physical signs of FGC.

Recommends that its members actively seek to dissuade families from carrying out harmful forms of FGC.

Recommends that its members provide patients and their parents with compassionate education about the physical harms and psychological risks of FGC while remaining sensitive to the cultural and religious reasons that motivate parents to seek this procedure for their daughters.

I stand by my original interpretation that the AAP left itself room to appeal to both sides of the argument. It brought up a ritual ‘nick’ for ceremonial blood, but avoided anything more declarative than hinting that it should be discussed. But it did not endorse female genital mutilation, unless one defines genital mutilation as any blade-to-genitals. (If that’s your definition, I agree from my rights-based perspective, but the same applies to male genital cutting.) If the goal is to reduce and eliminate harm to children, it’s stupid to suggest that we factor anything other than harm from non-therapeutic genital cutting and sexist to suggest the victim’s gender matters, somehow.

So, to be clear, I don’t have much respect for the AAP, for multiple reasons. It’s revised statement is cowardly. And I’m angry that the story has careened in a manner that requires me to defend an organization unable to reject non-therapeutic male circumcision, a practice it admits¹ is harmful. But here, with this statement, the AAP did not recommend that doctors perform female genital mutilation, nor did it initiate discussion of anything other than the least harmful forms of Type IV as a substitute for Types I, II, and III in a context where some form of genital cutting is likely.

To its credit the New York Times called the AAP:

A member of the academy’s bioethics committee, Dr. Lainie Friedman Ross, associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago, said the panel’s intent was to issue a “statement on safety in a culturally sensitive context.”

Dr. Friedman Ross said that the committee members “oppose all types of female genital cutting that impose risks or physical or psychological harm,” and consider the ritual nick “a last resort,” but that the nick is “supposed to be as benign as getting a girl’s ears pierced. It’s taking a pin and creating a drop of blood.”

I don’t accept that ear piercing is benign, but for the purposes here, Dr. Friedman Ross shows that the AAP did not say what many now hysterically claim it said. The now-accepted misunderstanding of its revision is unfortunate because there’s a relevant, necessary path for the discussion to take now that it’s opened:

Dr. Friedman Ross said, “If you medicalize it and say it’s permissible, is there a possibility that some people will misunderstand it and go beyond a nick? Yes.”

But she said the risk that people denied the ceremonial procedure, usually on the clitoris, would opt for the more harmful one was much more dangerous.

I’d like to see research to back that claim, but for some (probably significant) percentage, I have no doubt she’s correct. Unfortunately, the hysteria now present in the debate involves people who either have not read the revised policy statement or have poor reading comprehension skills, so we can’t approach that topic. (Remember, too, that I wrote that I favor of zero tolerance on this if you wish to accuse me of anything for pursuing the discussion.)

Instead, we’re left with people preening about an existing, incomplete (or inaccurate) narrative. The sentiment seems to be a determination to show that one cares about the issue in the correct way rather than figuring out how to minimize harm to children. I’m not saying that people who exhibit the former are uninterested in the latter, but they’re inadvertently working against the legitimate goal.

Post Script: I’d planned to include examples from other sources. Since they generally raise issues that are tangential to my objective in this post, I will address them separately.

¹ The AAP exhibits its cowardice by admitting this indirectly. It engaged in obvious moral relativism as it acknowledged that male circumcision is more harmful than what it proposed we discuss and that causing harm violates the physician’s “principle of nonmaleficence.” But the proper conclusion that non-therapeutic male circumcision is harmful and should therefore be prohibited on male minors is unavoidable from the bioethics committee’s statement on female genital cutting.

A Request

Seeing how the AAP’s revised policy statement on female genital cutting is inducing mass outrage, I think I need to revisit the issue. My initial analysis is very different from the basic, solidifying narrative. I’d planned to follow-up during lunch today, but there’s too much information to adequately address in this short time. I’m going to clarify my thoughts over the next day or so.

My request: I know people read what I write here about circumcision. If you read my blog entry on the AAP’s policy statement, let me know if you think there are any flaws in what I wrote, or if there are areas that I wasn’t clear. I want to make sure I get this right, but I’m perplexed that my take is so much different than what’s being said elsewhere. I don’t think I’ve misread the policy statement, but I want you to tell me I’m wrong if you think I have. Thanks.

Adam Wainwright Is Wrong

A fan ran onto the field during last night’s Phillies-Cardinals game, one night after a fan was tased for doing so. The volume of comments supporting the police officer’s use of the Taser on Monday night were appalling. The pre-emptive defense of deploying it again was inevitable. From Cardinals starting pitcher Adam Wainwright (emphasis added):

“That was tired, that was bad. You know what? The Phillies fans should be mad at that guy because he might’ve gotten in the way of Cole’s mojo he had going. That’s terrible timing. And if you don’t want to get Tased, don’t go on the field. There’s absolutely nothing wrong with getting Tased if you’re on the field.“

I’ll assume Wainwright isn’t aware that the Taser can be lethal, and that lethal force is never justified for trespassing. If I don’t assume that, I’ll think even less of him than I do after reading his obvious ignorance from that quote.

A Universal Standard of Basic Human Rights Isn’t Divided By Gender Or Culture

UPDATE:I corrected a word from the original entry to clarify my intent. I understand that the AAP is not a government organization. I’ve corrected the poor wording.

The American Academy of Pediatrics’ Committee on Bioethics issued a new policy statement on female genital cutting, titled “Ritual Genital Cutting of Female Minors”. It updates the organization’s previous stance. Mostly it’s predictable statements against all female genital cutting (FGC), which won’t be controversial in the United States. But there are a few bits of odd reasoning included.

From the abstract:

… The American Academy of Pediatrics opposes all types of female genital cutting that pose risks of physical or psychological harm, counsels its members not to perform such procedures, recommends that its members actively seek to dissuade families from carrying out harmful forms of FGC, and urges its members to provide patients and their parents with compassionate education about the harms of FGC while remaining sensitive to the cultural and religious reasons that motivate parents to seek this procedure for their daughters.

This is unobjectionable without focused reading. But it explains what is coming in the policy statement. Most Americans will read “opposes all types of female genital cutting that pose risks of physical or psychological harm” to mean no cutting should be permitted on healthy girls. The policy statement doesn’t refute that because, as it acknowledges, all non-therapeutic genital cutting on female minors is prohibited in the United States. In the body of the statement, this:

Protection of the physical and mental health of girls should be the overriding concern of the health care community. Although physicians should understand that most parents who request FGC do so out of good motives, physicians must decline to perform procedures that cause unnecessary pain or that pose dangers to their patients’ well-being.

Reading what isn’t being said demonstrates that the committee fails to endorse complete opposition to FGC, either. For example:

… Most forms of FGC are decidedly harmful, and pediatricians should decline to perform them, even in the absence of any legal constraints. However, the ritual nick suggested by some pediatricians is not physically harmful and is much less extensive than routine newborn male genital cutting. There is reason to believe that offering such a compromise may build trust between hospitals and immigrant communities, save some girls from undergoing disfiguring and life-threatening procedures in their native countries, and play a role in the eventual eradication of FGC. It might be more effective if federal and state laws enabled pediatricians to reach out to families by offering a ritual nick as a possible compromise to avoid greater harm.

I think there’s merit to this argument. It fits the details of proposed accommodations at Harborview Hospital in the ’90s for Somalian immigrants. From a practical standpoint, a ceremonial nick to draw a drop of blood is better than an excision. Discussion without invectives would be helpful.

However, I don’t want to imply that I endorse this strategy. I reject it as a matter of law and practice because children possess the same basic, natural human rights as adults. (There’s no distinction for the gender of the child, which I’ll address shortly.) Legislating such an exception, or refusing to prosecute such violations of existing law, legitimizes ritual and cultural genital alteration. It moves the discussion from should it be allowed to how much should be allowed. It dismisses the child, the individual whose genitals face the scalpel.

Related to that, the statement includes this:

There is also some evidence (eg, in Scandinavia) that a criminalization of the practice, with the attendant risk of losing custody of one’s children, is one of the factors that led to abandonment of this tradition among Somali immigrants.

There are options and paths to pursue before we embrace moral relativism.

Predictably, the statement avoids acknowledging American hypocrisy on the topic of male genital cutting. This is particularly worth noting as some seek to move the AAP’s (and assorted governmental bodies) official stance on non-therapeutic male child circumcision from its relative neutrality to deliberate advocacy. In the introduction of its updated FGC policy, it states:

The language to describe this spectrum of procedures is controversial. Some commentators prefer “female circumcision,” but others object that this term trivializes the procedure, falsely confers on it the respectability afforded to male circumcision in the West, or implies a medical context. …

Any fair, honest treatment of its words would recognize that male minors have the same rights. That excerpt should be rewritten to state that referring to female genital cutting as circumcision “confers on it the false respectability afforded to male genital cutting in the West”.

This follows the last excerpt:

… The commonly used “female genital mutilation” is also problematic. Some forms of FGC are less extensive than the newborn male circumcision commonly performed in the West. …

This is from the same organization that “opposes all types of female genital cutting that pose risks of physical or psychological harm.” The newborn male circumcision commonly performed in the West imposes objective physical harm in every case, yet the AAP refuses to reject it, preferring platitudes about parental choice. From the abstract of its policy statement on male child circumcision:

Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In circumstances in which there are potential benefits and risks, yet the procedure is not essential to the child’s current well-being, parents should determine what is in the best interest of the child. To make an informed choice, parents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision. If a decision for circumcision is made, procedural analgesia should be provided.

According to the AAP, parents may impose physical harm on their sons, violating the “principle of nonmaleficence” cited as a reason to reject FGC. Yet, in its revised FGC policy statement, the committee writes:

Parents are often unaware of the harmful physical consequences of the custom, because the complications of FGC are attributed to other causes and are rarely discussed outside of the family.

Changing “FGC” to “MGC” in that statement makes it no less accurate. Briefly perusing almost any news article or essay discussing male circumcision will reveal this.

Near its conclusion the committee writes:

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. Of course, parental decision-making is not without limits, and pediatricians must always resist decisions that are likely to cause harm to children. …

Including cultural, religious, and ethnic
traditions when making the choice of whether to surgically alter a male infant’s genitals is not legitimate. It is unethical, immoral and offensive to anyone who alleges to respect universal principles against causing harm. The committee’s second sentence shows its hypocrisy. It tells pediatricians to respect and aid parents who (ignorantly but unintentionally) wish to harm their sons. It’s moral relativism instead of clear principles respecting individuals. It’s unworthy of a civilized society.

Contrary to my initial concern, the revised policy statement does not explicitly advocate acceptance of lesser forms (i.e. Type IV) of female genital cutting. But it hints that it’s willing to look the other way if anyone wants to substitute Type IV for a type that won’t be practiced in the United States. Discussing such substitutions is a reasonable approach, but the committee cowardly avoids taking a stance, choosing to introduce the topic while letting others draw conclusions. It attempts to straddle both sides of the FGC debate to let each side read into its statement what it wants, if they’re unwilling to question or acknowledge anything that contradicts their preferred, limited viewpoint. Anti-FGC advocates are (correctly) upset, but the appeal of this approach is to those who believe that a potential benefit is science but the objective current health of a child is not. The AAP can plausibly say it opposes all female genital cutting, while also plausibly saying it recognizes the complexity of FGC as it’s practiced and is sensitive to the people who practice it on their children.

Individual Preferences Are Subjective

I recommend this month’s featured article at Econlib, “The Relentless Subjectivity of Value” by Max Borders. It’s in the context of economics, but anyone who reads my work here will surely recognize something familiar and useful. My favorite excerpt:

Nudging assumes a universal standard of well-being that simply cannot exist. For example, is it really that great to live longer? If foregoing scotch and bacon allows me to increase my life expectancy from 88 to 90, is it worth it to me? Will any amount of information possessed by folks at the Department of Health and Human Services cause me to see the light? I doubt it. I value my nightcap more than I value three more years at Shady Oaks. And I don’t want to hear “you’ll thank me when you’re 90” because, a) I’m not 90 and b) I may or may not enjoy the life of incontinence at Shady Oaks. Call me irrational, but if you do, you’re simply substituting your preferences for mine. Time, context and perspective count for a lot. Of course, none of this is meant to argue that your preferences or mine can’t be changed by either nudging or thoughtful advice. The point is that architecting choices means rigging the incentives in favor of another’s preferences, with no objective standard of value.

Again, even if you don’t care about the economics, it’s an interesting essay worth your time.

Fire Officer Beavis

This is why television broadcasts should show fans running on the field at sporting events:

… A Philadelphia police officer Tased a fan who ran onto the field before the eighth inning. The kid seemed to be running around and waving a towel, but police took no chances. In fact, neither did Jayson Werth. He readied himself for a possible altercation when the fan jumped onto the field near right field, but the fan quickly darted past him before being takent [sic] down in left.

The Phillies said in a statement: “This is the first time that a Taser gun has been used by Philadelphia police to apprehend a field jumper. The Police Department is investigating this matter and the Phillies are discussing with them whether in future situations this is an appropriate use of force under these circumstances. That decision will be made public.”

The Philadelphia Inquirer reported the fan has been charged as a juvenile with resisting arrest, disorderly conduct and defiant trespass. Police Commissioner Charles Ramsay defended the officer’s decision to Taser the juvenile.

“It was inappropriate for him to be out there on the field,” Ramsay told KYW Radio (1060-AM). “Unless I read something to the contrary, that officer acted appropriately. I support him 100 percent.”

An individual is tased for trespassing. Officials with the Major League Baseball team involved understands that this deserves scrutiny, talking about an “appropriate use of force.” [Disclosure: As I’ve made clear throughout my blogging, I’m a Phillies fan.] The police commissioner believes that the officer was justified in tasing the individual because trespassing is “inappropriate”. This should scare everyone.

Of course trespassing is inappropriate, as the property owner controls his property and every sports team has a policy against fans entering the field of play. But tasers can be lethal. Would the cop shoot the kid in the back with his firearm for this? Was he just compensating for being out-of-shape and not wanting to engage in the physical confrontation necessary to subdue the individual? The taser, as it’s being used, isn’t a tool for police to do their job. It’s now a substitute. That is worthy of actions to rein in police, not chuckles.

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For reference, watch this video about a suspect who died after police tased him. There are many implications, but notice how the spokesman blamed the now-dead suspect for getting himself tased and subsequently choking on a bag of marijuana he’d previously, visibly shoved in his mouth. Is that the mentality we want to endorse for any police force?