Logic – Page 7 – Rolling Doughnut

Consent plays a role, too.

This article on adult circumcision was the companion piece to the recent Los Angeles Times article on infant circumcision. It would’ve been easy and proper to focus on consent, here and in the article on infants, but instead it’s mostly fluff seemingly intended to prove that men really, really like circumcision. The facts don’t support the article’s implications, although you have to know the facts because they weren’t provided in the article. I suspect this is mostly because the reporter lazily relied on urologists, who will inevitably see only men with an issue. Healthy, happy intact men don’t generally visit a doctor to say everything’s fine.

Still, I found one useful nugget (emphasis added):

Dr. David Cornell, a urologist who runs the Circumcision Center in Atlanta, sees men who want a circumcision because they prefer the appearance and because they want to feel more comfortable socially.

“I hear a thousand times a year from men who don’t feel that they look like most other men in the locker room. In our society, there’s an overriding preference for circumcision,” says Cornell, who performs 250 procedures a year on men who, for cosmetic reasons, want a circumcision or a revision to one they don’t think looks right.

Even where the male eventually agrees with his parents and/or society’s subjective judgment that circumcision is more aesthetically appealing, what is specifically appealing is also subjective. Dr. Cornell surgically alters (consenting¹) circumcised men toward the body they want. This part of his practice demonstrates that even when parents guess correctly, there is no guarantee that this will be sufficient.

Of course, men could also choose this if left intact, with a better chance of getting exactly what they want² because they have everything to work with, rather than the remnants of the original circumcision.

¹ Also from the article:

Though frequently attacked by anti-circumcision activists, [Dr. Cornell] says, “I’m doing a cosmetic operation on a consenting adult. Why he’s doing it is his business.”

He’s correct. Those activists damage the legitimacy in this debate. Circumcision is only the expression of the real issue, the lack of consent from healthy minors whose genitals are surgically altered.

² Or what they think they want. I know at least one man whose parents did not circumcise him. He chose it for himself as an adult to conform to societal expectations. He hates the results and regrets his action.

This “flexible and compassionate” is misdirected.

This article appeared in the Boston Globe last week. It’s a discussion of efforts to train new mohels in Massachusetts. Two particular passages are relevant to my focus. First:

Be flexible and compassionate, [Dr. Bob] Levenson told the doctors. … Gently tell the truth when a tearful, post-partum mother asks if babies can feel pain. (The answer is “yes, but I’ll be as quick as possible”). And it is perfectly OK – recommended, even – to anesthetize the infant with a little kosher wine dabbed on the lips.

Beyond wanting to see evidence that wine dabbed on the lips of an infant male will anesthetize him from the pain of surgery, this issue raises a large ethical red flag. There must be an objective reason to inflict pain on another, particularly a child who can’t offer (his) consent. And does the infant male’s soon-to-be-removed foreskin serve a purpose? The answer is “yes,” no parenthesis necessary or appropriate.

Second:

But for doctors, the work is not considered particularly lucrative. Mohels must secure their own malpractice insurance, spend significant time counseling families, travel, perform the ceremony on the eighth day of a child’s [sic – male] life, all for a fee of $350 or $400.

If a religious observation requires medical malpractice insurance, it is only legitimate to perform on consenting adults. The individual right of minors to be free from (medically unnecessary) harm must remain the exclusive standard, superior to any religious requirements, because risk is objectively inherent. The evaluation of that medically unnecessary risk against unverifiable religious benefits is subjective. The conclusion is only legitimate from the individual giving up his foreskin.

A libertarian argument for a new law.

Mark, who writes the excellent Publius Endures, left an excellent (and appreciated) comment over the weekend. Normally I would reply there, as I do with most comments. But Mark included one point that I’d like to discuss (emphasis added).

I must say that the circumcision debate (to the extent it can even be called that) has made me feel relieved that my wife and I are having a girl since we don’t even have to consider the issue. Circumcision is frequently done almost without thought, essentially as a ritual. Until Andrew Sullivan started blogging about it in the last few years, it was an issue that I didn’t even consider – I thought it was something that was just what was done. People like you and Sully are starting to open eyes that the practice largely lacks any kind of basis other than as a cultural norm.
The main reason to perform circumcision, as far as I can tell, is that it may create some awkwardness when the child becomes a sexually active adult. The thing is that by the time that becomes an issue, the child will be more than capable of making the decision on his own.
If we had our child a year ago (and it was a boy), I think I would have opted for circumcision just based on the fact that it is a social norm and that there is little publicity about the arguments against circumcision. Were the decision to come up now, I would almost certainly not circumcize.
I’m not sure the procedure should be made illegal, though, but only because I’m generally opposed to adding new laws. However, parents need to be better informed about the risks and generally nonexistent benefits of circumcision.

Before I respond, allow me to clarify that this is in no way meant to condescend on this (or any) point. Although I’m certain that I’m right in all facets of my approach, I’ve thought about this every day for many years. I’ve read a lot of bad arguments on both sides. Reading through them can be tiresome, and without self-monitoring, my response can fall into frustration. (I try to avoid outright disdain, even though there are places where it’s richly deserved.) Mark’s comment is none of that. He shows an open mind that demonstrates genuine intellectual curiousity. He grasps the fundamental argument against male infant circumcision and is willing to act based on that new knowledge. Or to not act, based on that new knowledge. I wish more people had that kind of integrity.

Nor am I suggesting that he does not understand any of the libertarian approach I advocate here. Allow me to reiterate, if you’re not reading Mark’s blog, add it to your RSS feed today. His libertarian credentials are well written in his entries. Here, I’m only offering how I think a libertarian approach must be applied. I’ve read that libertarian arguments don’t apply to children. I find that strange, so this is at least tangentially a refutation of that.

To his comment, though, I think there’s an easy libertarian argument that demands legal prohibition. The Female Genital Mutilation Act of 1995 exists. As long as it is valid law, restricting all medically unnecessary genital cutting on female minors, even at the request of parents, the 14th Amendment demands that the government treat citizens equally. The only choices are to repeal the FGM Act or make the law gender neutral. Since we all agree that the former is unacceptable, we’re left with the latter. (Take a look at the work Matthew Hess is doing to achieve an MGM Bill.)

Beyond that, viewing government through a libertarian goal of maximizing liberty, I’m against any law that would restrict people from making that decision for himself (or herself). I can form whatever opinion I want about someone’s decision, but it’s irrelevant to what he should be able to do to himself. Weigh the benefits against the harm with whatever consideration makes sense. But the issue at hand is that medically unnecessary surgery is objectively identifiable as harm. There is cutting. There is an inherent risk of complications, both minor and severe. And infants do not have their choice. Objective harm is forced on them without their consent with no medical need or objective benefit.

Statistics demonstrate that, when left with their choice, males almost never choose or need circumcision. Any reasonable person standard must side with not removing healthy body parts from children. They have the same individual rights that every adult has to the extent that a right is inherent and inalienable. For minors, those rights should be viewed as held in trust rather than created upon reaching the age of majority. Since the first legitimate purpose of government is to protect the rights of each citizen against infringement by other citizens, there is no reason to overlook that just because the person imposing the harm is a parent who views the imposition as beneficial in some (subjective) manner.

Again, I don’t think Mark’s comment indicates that he’s willing to overlook anything. He’s not rejecting a law. But as he points out there is a societal norm in the United States that male circumcision is just an inconsequential snip. As I’ve demonstrated throughout my circumcision category, it’s not true that it’s inconsequential. Even though most American men are content to be circumcised, we are a nation of individuals before any other examination. Adding a new law to include boys protects them as individuals in the same we already protect girls. It is a law that actively advances individual liberty, while actively rejecting an incoherent narrative of liberty dressed in parental “rights”.

We shouldn’t need a law to protect against infant circumcision. But in a perfect world, parents wouldn’t remove healthy body parts from their children out of fear, superstition and conformity. We must legislate for the world we have, with the foundation of individual rights that we know is valid. I could make an argument that existing assault laws cover unnecessary infant circumcision, but no prosecutor is going to pursue that in the common circumstances of male infant circumcision in America. So, barring a sudden shift to rational action by parents, this is an area where the government must legitimately exercise its authority in defense of rights.

Post Script: There’s a little more to Mark’s comment than what I posted here. I left an additional response there, but it was more anecdotal.

Delicate Decision: Post 4 of 4

On Monday the Los Angeles Times offered a typical analysis of infant male circumcision. There are many points to address from this story, so I’ve broken them up into multiple posts. (Posts 1, 2, and 3.)

Point four:

FOR nearly all of Nada Mouallem’s pregnancy, she and her husband, Tony, had a running argument. She wanted to have their son circumcised. He didn’t. “Many days, I’d go off and research all the pros. He’d go and research all the cons. Then we’d get together at night and fight,” she says.
…

For the Mouallems, family tradition and religion were not factors. “We kept those separate and focused only on the scientific reasons,” says Tony Mouallem, who was against circumcising his son because he didn’t think it was necessary. Plus, he’s not circumcised. “You have to work a little harder to keep it clean, but that’s not a big deal.”

His wife, Nada, however, worried about the responsibility of keeping her newborn’s penis clean. She thought circumcision would help reduce the risk of infection and disease. “I wasn’t keen on my baby having a surgical procedure, but then I thought, why not if we can offer him more protection?”

In the end, Tony sided with his wife. Their son was born Feb. 10, and was circumcised the next day. Tony held him during the procedure. “There was no bleeding and he didn’t even cry,” he says. “I’m still not convinced it was medically necessary, but I didn’t want to burden my wife with the worry of cleaning it. And maybe it will be easier for him in the locker room.”

Choosing surgery over responsibility is the abdication of an obligation when having children. No one states that an intact penis can’t be kept clean. Even ignoring the absurdity that it’s more difficult to clean in his early years when his foreskin adheres to his glans and shouldn’t be retracted, keeping your children clean and eventually teaching them to care for themselves is parenting. Anything else is the selfish subjugation of the child’s needs to the parents’ whims. In this case, that whim is further discredited because the father presumably understands how to keep an intact penis clean.

Post Script: This most fits the “typical” analysis. These “balanced” articles always contain a couple who can’t decide. And the couple always chooses “yes”.

More analysis of this article and the CDC’s obtuse approach can be found here and here at Male Circumcision and HIV.

Delicate Decision: Post 3 of 4

Point three:

Robert and Cara Moffat of Los Angeles, who are expecting their first child, a boy, in May, had no trouble deciding, and plan to have their son circumcised. Robert, who is 30 and circumcised, said, “I grew up with it, and my wife has a preference for it, so that’s what we’ll do. We’re doing what the family is comfortable doing.”

His father is happy being circumcised, so the boy will be happy with it. This is an unverifiable assumption at birth. His mother prefers having sex with circumcised partners. This is irrelevant because I presume she does not intend to have sex with her son. So it leaves the conclusion that his future sex partner(s), who they apparently know will be female, will prefer that he be circumcised. This is an unverifiable assumption at birth. Finally, “what the family is comfortable doing” is hardly a principle of ethics, liberty, or science.

Also note that the parents have said nothing about (potential) medical benefits in forcing this on their son. Yet, they’re allegedly qualified to decide that their son will want this. And legally we’re all supposed to think this is reasonable.

As parents and task forces sort through the variables surrounding this intimate decision, [Dr. Andrew] Freedman offers parents in turmoil this comforting advice: “Rest assured. No matter what decision parents make for their son, most men think whatever they have is just fine.”

There are four potential realities for an adult male when he is finally legally protected to make his own genital decisions the way females are protected from birth. He can be intact and happy. He can be circumcised and happy. He can be intact and unhappy. He can be circumcised and unhappy. In the first scenario, he could do something but he wouldn’t. In the second, he can’t do anything but he doesn’t care. In the third, he can do something and he will choose either the perceived benefits of circumcision he seeks or not facing the drawbacks from adult circumcision. In the fourth, he can do nothing and society rejects his opinion as an individual.

In the first two scenarios, we conclude that the child validates the parents’ decision. We mistake an unrelated outcome for causation. In the third scenario, whatever we conclude, we’ve achieved the minimum standard of liberty that the male retains his right to choose (or reject) medically unnecessary procedures. In the fourth scenario, we either deny its validity or babble on about the rights of the parents. This generally involves some hand-wringing about parents making lots of tough choices while actively missing that none of the other choices involve removing parts of his anatomy. (You didn’t forget that parental rights are greater when speaking of sons, did you?)

Dr. Freedman’s opinion tells every man in scenario four his parents’ opinions about his penis matter more than his own. Anyone who argues this refuses to reconcile the complete lack of medical need with any notion of ethics and individual rights. Just because science can (allegedly and potentially) achieve an outcome does not mean it should try to achieve that outcome. That is a slippery slope unbounded by any consistent rule or principle.

More analysis of this article and the CDC’s obtuse approach can be found here and here at Male Circumcision and HIV.

Delicate Decision: Post 2 of 4

Point two:

In the first year of life, 1 in 100 uncircumcised [sic] boys will develop a urinary tract infection. Only 1 in 1,000 circumcised boys will. “While that’s a tenfold reduction, you have to keep in mind that the risk was only 1% to begin with,” says Dr. Andrew Freedman, pediatric urologist at Cedars-Sinai Medical Center. Proper hygiene can prevent most infections.

When considering potential benefits, context matters more than an isolated statistic. For example:

The downside of letting the child make the decision later is that adult circumcision is more expensive, painful and extensive. During an infant circumcision, practitioners numb the site with local anesthesia, then attach a bell-shaped clamp to the foreskin and excise the skin over the clamp. The clamp helps prevent bleeding. In adults, the procedure involves two incisions, above and below the glans (tip of the penis), stitches and a longer recovery. The cost is about 10 times that of a newborn procedure.

Let’s ignore the rights of the individual for the moment. I don’t, but the hypothetical does, so I’ll stick with it. The cost is about 10 times that of a newborn procedure. So what? As a fact on its own, it means nothing. How likely is it that an intact male will need circumcision in his lifetime? If it’s less than 10%, and it is, then a basic cost-benefit analysis shows that we will spend less overall by circumcising only those males who medically require circumcision. The “ten times more expensive” meme is worthless upon minimal inspection.

Dr. Freedman seems to understand this:

“The HIV data is the most compelling to date that circumcision can help prevent the transmission of the virus in male-female sex,” Freedman says. “While this is important to sub-Saharan Africa, the question is how many infant boys need to be circumcised in the United States to prevent one case of HIV transmission 25 years from now? Factoring in even the rare complication that can occur with circumcision may render this study insignificant.”

No kidding. Aside from not being able to predict who (or if) circumcision will help prevent HIV, we can also not predict who will suffer a complication. I seriously doubt the few children who suffer a significant mutilation of the penis care that most circumcisions are “successful”. Nor do I suspect the few boys who die from circumcision care about the general outcome. Of course, this should matter now, even before reducing a child to his (unknown) place in the statistical herd.

But he might not get it:

If parents do opt for the procedure, Freedman advises that they do it when the baby is a newborn, have someone trained and experienced perform the procedure, and use pain control. “The older a child gets, the less benefit there is, and the greater the risk,” he says. “I would ask parents of an older child to strongly reconsider if the only reason they’re doing this is cosmetic.”

The parents of a newborn who choose circumcision for cosmetic reasons? Those are somehow okay? Again, the individual – the patient – matters. When he is healthy, every other outside opinion is meaningless to the consideration of his body.

More analysis of this article and the CDC’s obtuse approach can be found here and here at Male Circumcision and HIV.

Delicate Decision: Post 1 of 4

Point one:

Dr. Peter Kilmarx, chief of epidemiology in the CDC’s division of HIV/AIDS prevention, says the CDC is looking at how the findings apply here. “The early opinion from the consultants — and not the position of the CDC, which involves a peer review process and public comment — is that, given all the previous data on circumcision plus the recent HIV African studies, the medical benefits of male infant circumcision outweigh the risks and that any financial burden barring parents from making this decision should be lifted,” he said.

Nationalizing health care will no more end routine infant male circumcision in America than the elimination of Medicaid funding has ended it in the states where Medicaid no longer pays for the unnecessary procedure. There is a political constituency that strongly supports imposing this on children. Until the universal principle that each individual owns his or her body is codified into law for males the way the Female Genital Mutilation Act now protects female minors, medically unnecessary circumcision will continue. And the state will pay for it when parents can’t (or won’t). Any protection of the individual based on entrenching an existing, or establishing a new, collective will fail.

Here’s a half-point in which I doubt Kilmarx understands the missing half:

“The procedure is so ancient, and steeped in cultures, I’m not surprised that the rate of adult circumcision in civilized countries doesn’t track with medical evidence,” Kilmarx says. “But as scientists, we don’t solely rely on what other countries do as a guideline.”

But as Americans, we don’t (mustn’t) solely rely on what science tells us as a guideline. Ethics matters. The rights of the individual matter, particularly the healthy individual. There is a hierarchy for decision-making concerning surgery on children. Kilmarx, among many, does not start at the beginning (i.e. medical need). That leads to mistakes, as clearly shown by the million-plus unnecessary infant circumcisions performed every year in America.

More analysis of this article and the CDC’s obtuse approach can be found here and here at Circumcision and HIV.

Quote of the Day: Yesterday Edition

Megan McCardle sums up the libertarianism approach to governing:

“It won’t work” is the easiest prediction to get right; almost nothing does. The thought process that tells you something probably won’t work is not always a good way to figure out what will, even if you were right for the right reasons, as I agree lots of people were. That’s why libertarians have a great track record at predicting which government programs will fail (almost all of them) and a lousy track record at designing ones that do work.

But libertarians are generally smart enough to realize that we aren’t qualified to design a government program. (No one is, libertarian or not.) The prediction guides the desire not to plan. There are government plans, of course, unless one moves beyond a minarchist approach into anarcho-capitalism. And they will most likely not work as planned. We are smart but we are not the next Nostradamus. We remember that our first objective is the maximization of individual liberty. Thus, we seek to limit government to the barest necessity, to wreck as little as possible.

Our gender discrimination permits this immoral argument.

Following on previous entries regarding female genital mutilation, John Tierney updates the conversation with an opinion from Dr. Fuambai Ahmadu, “a native of Sierra Leone, who grew up in America and then went back to her homeland as an adult to undergo the rite along with fellow members of the Kono ethnic group.” I’m not impressed with Dr. Ahmadu’s reasoning.

I also take note of readers’ concerns about consent. While I have serious issues with the concept of consent and how it is applied asymmetrically to African practices of female genital cutting, I do agree with Rick Shweder that a possible way forward would be to consider limiting certain types of genital cutting to an age of majority, for instance, the age at which a girl can consent to marriage, abortion or to cosmetic surgery. A minor procedure can be allowed for girls under the age of consent, as is the case with infant male circumcision. Defining what such a minor procedure would entail and what might be the appropriate ages of consent is an important step that must include the voices of the “silent majority” of women who are affected.
…

The way forward is to look for solutions that would empower women (and men) to choose what to do with their own bodies. …

My position is “pro-choice” on any form of female and male genital modifications (with the exception of minor cuts, such as circumcisions of male and female prepuce discussed above) and a complete rejection of the motto “zero-tolerance of FGM”. …

That’s an interesting notion of choice. Dr. Ahmadu conflates the prerogative of a cultural group¹ to exclude those who do not conform to its rituals with permission to require inclusion through involuntary participation among those who reject its rituals. This ignores the real issue, the use of force on a healthy, non-consenting individual.

Pro-choice should mean what it implies, which is complete consent or refusal. There are no other valid competing interests on the individual when critiquing elective genital surgery. If the person agrees, for whatever reason, it is his or her choice. If the person does not agree, for whatever reason, it is forced. If the person cannot consent, for whatever reason, the assumption must be that he or she would not. Force violates his or her rights as an individual to self-ownership. Permitting force relegates the body part(s) under consideration to property status, possessed without limitation by another. That can never be right.

Introducing subjective qualifications (i.e. minor cuts) is then a diversionary tactic based on a relativist notion of what people should not mind based on the good opinion of others. It is not a principle that recognizes the individual. It rejects a coherent conception of human rights.

Dr. Ahmadu’s minor is my major. Her blessing of my forced circumcision as a cultural rite is irrelevant to the point of offensiveness. I believe in choice. She believes in choice, unless force is necessary to achieve her outcome.

Post Script: Dr. Shweder contributed a comment to the discussion suggesting a curious denial of some of the earlier counterpoints made throughout the threads. I offered a new rebuttal here.

¹ Do not read this as a synonym for government. No government has such authority, nor do citizens possess a right to use government to exclude citizens from society.

Can we frame the debate objectively?

In response to this Will Wilkinson entry and this Kerry Howley entry on the liberty arguments for (economics) and against (morality) legalized prostitution, Ross Douthat goes off the rails with a strange question of how prostitution as sex work differs from molestation and incest. It’s as ridiculous as it sounds. Read Mr. Wilkinson’s response, with all the obvious goodness such a question demands.

Instead, I want to focus on this one sentence from Mr. Douthat’s entry:

If you think that sex, by virtue of being bound up not only culturally but biologically with emotional attachment on the one hand and reproduction on the other, is a unique kind of physical act, one that’s intimate by its very nature in a way that, say, preparing dinner isn’t, then it makes sense to assign a hierarchy of moral value (and moral stigma) to different kinds of sexual activity – most likely with monogamy at the top, serial monogamy somewhat lower, promiscuity lower still, and activities that treat sex as a commodity to be bought and sold somewhere near the bottom.

Of course it makes sense to assign that hierarchy if that’s what you think. But not everyone thinks that. Perpetuating individual liberty demands more than caving to a squishy notion of universal disdain for an activity. Even, and perhaps especially, when one finds activities at the bottom of that hierarchy morally repugnant.

The validity of arguing for the legalization of prostitution does not hinge on the moral argument with regard to selling sex. It is acceptable to believe that an activity is morally unacceptable, yet to acknowledge that two consenting adults may engage in that activity because they are not harming others. Or more precisely, if they are harming anyone, it is only themselves, voluntarily. That question of liberty is at the core of this debate, not the moral defensibility of prostitution.

Free to engage and should engage are different concepts. Ms. Howley and Mr. Wilkinson argue only the former. This (implicitly) injects into the debate the truth that all tastes and preferences are subjective. It sets such subjectivity aside and leaves the legal question only to evidence of objective harm.

For fairness, Mr. Douthat posits in an earlier entry that sex work is by definition self-abuse, justifying a legal prohibition. The posts he responds to in the above links address that argument.

**********

Of course, since it’s apparently okay to ask questions unrelated to the topic, let me ask a question: Why is it automatically self-harm worthy of prohibition for an individual to sell sex, even when it’s voluntarily sold, yet it’s reasonable to permit parents to surgically alter the genitals of their healthy sons – who may or may not approve of such permanent, physical alteration – as Mr. Douthat suggested last year in defense of infant circumcision?

The answer to how one person can hold two incongruent opinions rather obviously rests in a willingness to use personal, subjective tastes and preferences to inform the legal code of a diverse, secular, civil society. It’s the same central planner impulse that resides in every individual who seeks to dictate which freedoms are abhorrent.

Since I’m off on the tangent, in that entry, Mr. Douthat states:

Proponents, like myself, point out that even saying the word smegma is really disgusting. Again, I think we pretty much win the debate right there, without even getting into the whole HIV question.

I get the tongue-in-cheek nature of the comment, whether he meant it or not. I think he did because I think he views circumcision as inconsequential. (Remember subjective tastes and preferences?) But any understanding of human biology demonstrates the stupidity of such an argument. Female genitals produce smegma, as well. We do not cut female minors for that reason. Or, more to the point, we do not permit parents to cut their daughters just because they, the parents, are disgusted by the mere mention of the word. We manage to find the correct reasoning to prohibit that. But for males, parents can use only the mere mention of smegma as an excuse to cut. Or they can reject even that reason and order it because it’s fun to check “yes” on the consent form. The law is based on our conditioned beliefs rather than facts.

Just as it is with prostitution.