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Bioethics ISSN 0269-9702 (print); 1467-8519 (online) Volume 29 Number 7 2015 pp 507–515

doi:10.1111/bioe.12141

THE ENHANCEMENT OF CHILDREN VERSUS CIRCUMCISION: A CASE OF DOUBLE MORAL STANDARDS? TOBIAS HAINZ

Keywords human enhancement, circumcision, human nature, right to an open future

ABSTRACT The application of enhancement technologies to children and non-medical infant male circumcision are both topics that enjoy the continuous attention of bioethical research but are usually discussed in isolation from each other. Yet one can show that three major arguments used by opponents of the enhancement of children are also applicable to circumcision. These arguments are based on the insecurity of these procedures, the child’s right to an open future, and human nature as a foundation of human dignity. People who reject the enhancement of children because of these arguments but accept circumcision hold mutually inconsistent moral convictions or apply double moral standards to these cases. This is particularly important when legislative systems treat the enhancement of children and circumcision in a considerably different manner, which is true for many contemporary legislative systems. At least three strategies can be adopted in order to avoid such inconsistencies, two of which, however, fail for various reasons. According to a third, more promising strategy, circumcision should be subsumed under human enhancement and treated like other enhancement technologies. This strategy justifies restrictions on, but not the prohibition of circumcision. Furthermore, proponents of circumcision should be prepared for future technologies that provide similar benefits as circumcision but are not as contentious as this intervention, so that, in the future, circumcision could become more and more unacceptable.

INTRODUCTION Infant male circumcision (henceforth: circumcision) and human enhancement, especially in the case of children, are both controversial topics that enjoy the continuous attention of bioethical research. Although both topics are usually discussed in isolation, they can be closely associated with each other by pointing out that three major arguments that are usually advanced against the enhancement of children are also applicable to circumcision. One can identify several properties both phenomena have in common: circumcision is a procedure that has a considerable influence on the bodily properties of a child, since it has the potential to be dangerous, and it should be regarded as irreversible unless we find feasible ways to reverse its effects. This leads to circumcision being an

insecure procedure, both because of its potential to be dangerous and because of its irreversibility. This can also be said of many forms of human enhancement because it could have unforeseen and undesirable consequences and it could be irreversible, at least in the case of enhancements achieved through genetic engineering. A further property shared by circumcision and human enhancement is that they will shape not only the present life of a person but also his future in the long term: a boy with a circumcised penis will have to live with it, and he might enjoy this life, but he could also struggle with his sexuality because of this early intervention. This can also be said of human enhancement because an enhanced child will not only behave differently from an unenhanced child, but its actions that are the result of the enhancement might be sufficient for bringing about a different future for this

Address for correspondence: Tobias Hainz, Hannover Medical School, Institute for History, Ethics, and Philosophy of Medicine, Carl-Neuberg-Str. 1, 30625 Hannover, Germany. Email: [email protected] Conflict of interest statement: No conflicts declared © 2014 John Wiley & Sons Ltd

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particular child. The third property shared by circumcision and human enhancement does not so much pertain to their effects but to the processes themselves: both can be regarded as unnatural because they alter the biological capacities of people in a way that would have never occurred if the procedures had not been undertaken. This unnaturalness of circumcision and human enhancement can be interpreted as a threat to human dignity, at least if one postulates a close relation between human nature and human dignity. In this article, three arguments against human enhancement will be considered, with a focus on the enhancement of children: the argument from insecurity, the argument from the right to an open future, and the argument from human nature. The main aim of this article, however, is not to support or to challenge these arguments but to argue that whoever accepts these arguments in the case of human enhancement should also accept them as arguments against circumcision. There is no good reason to reject the enhancement of children with reference to these arguments and accept circumcision, as this would be an instance of double moral standards. This result is less important for the case of individual people who would simply hold mutually inconsistent moral convictions, but it is more important in the case of institutions like governments because these institutions have the power to shape the lives of a huge number of individuals, including children. Institutions like governments are typically highly protective of children when it comes to fundamental modifications of their biological properties, such as human enhancement. Evidence for this protectiveness includes legislative or regulatory documents, such as the United Kingdom’s Human Fertilisation and Embryology Act in its 2008 version1 or the German Embryo Protection Act.2 Both documents prohibit the implantation of an embryo with a modified DNA into a woman’s uterus, even if this modification would enhance properties of this embryo. Further evidence includes statements by national ethics councils, such as the (dissolved) President’s Council on Bioethics in the United States,3 that discourage the application of enhancement technologies to children. On the other hand, circumcision is legally permitted in these countries, so that one can recognize a clear difference between governmental attitudes towards the enhancement of children and circumcision. 1

The National Archives. Last updated 2008. Human Fertilisation and Embryology Act. Available at http://www.legislation.gov.uk/ukpga/ 2008/22/contents [cited 2014 September 3]. 2 Bundesministerium der Justiz und für Verbraucherschutz. Last updated 2011. Gesetz zum Schutz von Embryonen. Available at http:// www.gesetze-im-internet.de/eschg/BJNR027460990.html [cited 2014 September 3]. 3 The President’s Council on Bioethics. Beyond Therapy. Biotechnology and the Pursuit of Happiness. Washington DC: The President’s Council on Bioethics; 2003.

I will focus on circumcision where it is not medically indicated. An inflammatory disease known as ‘balanitis xerotica obliterans’ or other conditions may necessitate circumcision as a treatment,4 so that one can distinguish between medically indicated and not medically indicated circumcision. While circumcision is a central ritual in Judaism and Islam, it is also prevalent among people who do not belong to these religions in various regions of the globe,5 so that it can be regarded as a socially established practice in these regions.

THREE ARGUMENTS AGAINST ENHANCING CHILDREN The first argument presented, the argument from insecurity, can be applied to human enhancement in general, but it can have more force when applied to the case of enhancing children. Francis Fukuyama is one proponent of this argument when he raises objections to genetic engineering of children. He presents several obstacles we should be able to overcome before we can seriously think about genetically modifying children, two of which are of special relevance for this article: genetic complexity and multiple causal pathways.6 There are highly complex interdependencies between genes and their effects on the phenotype, so that altering one gene can have unpredictable and undesirable consequences. These obstacles may provide reasons for refraining from genetically engineering children or being extremely cautious about. It could be worse to genetically engineer children than adults, because children would have to deal with the possibly harmful consequences for a longer period of time. Since the concerns expressed by Fukuyama involve complexity, limited knowledge and unintended as well as undesirable consequences, they can be summarized as concerns regarding insecurity. Fukuyama suggests that preimplantation genetic diagnosis or genetic engineering as methods of enhancing children should be restricted although they could also be used and accepted for therapeutic purposes.7 This suggestion can be regarded as the conclusion of an argument from insecurity: technologies like these are highly insecure procedures, if used for the purpose of enhancement, that could endanger the children they are performed 4

S. Celis et al. Balanitis xerotica obliterans in Children and Adolescents: a Literature Review and Clinical Series. J Pediatr Urol 2014; 10: 34–39; T. Drake, J. Rustom & M. Davies. Phimosis in Childhood. BMJ 2013; 346, doi: 10.1136/bmj.f3678. 5 World Health Organization. Male Circumcision. Global Trends and Determinants of Prevalence, Safety and Acceptability. Geneva: World Health Organization; 2007. Available at http://whqlibdoc.who.int/ publications/2007/9789241596169_eng.pdf [cited 2014 May 21]. 6 F. Fukuyama. Our Posthuman Future. Consequences of the Biotechnology Revolution. New York: Picador; 2002. p. 77–78. 7 Ibid: 208.

© 2014 John Wiley & Sons Ltd

The Enhancement of Children versus Circumcision upon. However, it is impermissible to perform such insecure and potentially harmful procedures upon children, which is why using them as enhancement technologies should be restricted. A further analysis of this topic is conducted by Jason Borenstein8 who does not categorically reject the genetic enhancement of children but observes it with scepticism because of the harm it could inflict on children. The recommendation he gives is not to ‘proceed with the technology without broad public discourse about its ethical implications’.9 Finally, Philip M. Rosoff10 accuses both proponents and opponents of genetic engineering of being overly optimistic and pessimistic, respectively, about its possible effects. He also identifies insecuritybased reasoning in the camp of the opponents of genetic engineering.11 Genetic engineering is just one possible form of human enhancement since there are other forms that can be imagined in the case of children, such as administering drugs to healthy children in order to enhance their capacities. However, the argument from insecurity is still applicable to these other forms of enhancement: one can raise concerns regarding the safety of using medical treatments as enhancement technologies because of the complexity of human physiology.12 While the argument from insecurity might be more powerful in the case of genetic engineering, its applicability to other forms of human enhancement is mostly a matter of degree, not a matter of principle. For, even if we know more about, say, the pharmacodynamics of a drug usually given as a treatment to children who suffer from a specific disease than about the effects of a particular genetic modification, a significant degree of insecurity about the effects of this drug could still be involved if it were administered to a healthy child for the purpose of enhancing some of its properties. The argument from insecurity might lose some of its strength in cases like these if more and more information about the effects of a drug on healthy children were discovered, but its applicability could only be disputed in principle if all relevant information were available. One might be tempted to claim that the argument from insecurity becomes irrelevant when a sufficient amount of information about its effects is available and, at the same time, there are decisive reasons for administering a drug to healthy children. Yet this strategy – which can, of course, 8

J. Borenstein. The Wisdom of Caution: Genetic Enhancement and Future Children. Sci Eng Ethics 2009; 15: 517–530. 9 Ibid: 529. 10 P.M. Rosoff. The Myth of Genetic Enhancement. Theor Med Bioeth 2012; 33: 163–178. 11 Ibid: 174. 12 W.D. Graf et al. Pediatric Neuroenhancement: Ethical, Legal, Social, and Neurodevelopmental Implications. Neurology 2013; 80: 1251–1260; N. Gaucher, A. Payot & E. Racine. Cognitive Enhancement in Children and Adolescents: Is It in Their Best Interests? Acta Paediatr 2013; 102: 1118–1124.

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be successful – does not aim at disputing the applicability of this argument but its relevance in a particular context. The argument from insecurity can, therefore, be applied to genetic engineering as one form of enhancement but to other forms of the enhancement as well. The argument from the right to an open future is based on Joel Feinberg’s classic analysis of different kinds of rights, including the so-called ‘rights-in-trust’:13 [Rights-in-trust] are to be saved for the child until he is an adult, but which can be violated ‘in advance’, so to speak, before the child is even in a position to exercise them. The violating conduct guarantees now that when the child is an autonomous adult, certain key options will already be closed to him. His right while he is still a child is to have these future options kept open until he is a fully formed, self-determining adult capable of deciding among them. . . . Put very generally, rights-intrust can be summed up as the single ‘right to an open future,’ but of course that vague formula simply describes the form of the particular rights in question and not their specific content.14 Feinberg clarifies that although one might speak of a ‘right to an open future’, one actually has to investigate whether a specific procedure violates one of a child’s rights-in-trust in order to arrive at a justified conclusion. Human enhancement and especially genetic engineering – as one form it can take – is one such procedure that could constitute a violation of children’s right to an open future. Dena S. Davis, for example, is among those who apply the concept of a right to an open future to certain forms of genetic engineering, such as sex selection and the creation of disabled children,15 which would usually not count as instances of human enhancement. However, Davis also argues for weighing the right to parental autonomy against the child’s right to an open future in other cases where parents attempt to enhance their children’s abilities and capacities.16 One can imagine various forms of human enhancement that can prima facie be regarded as sufficient for constituting a violation of children’s right to an open future. Parents who enhance the physical capacities of their child because they want it to become a successful athlete could, thereby, narrow their child’s options regarding its future professional career. On the other hand, parents who concentrate on their child’s mental capacities could also steer their child’s future into a certain direction, thereby 13 J. Feinberg. The Child’s Right to an Open Future. In J. Feinberg, Freedom & Fulfillment. Philosophical Essays. Princeton: Princeton University Press; 1992. p.76–97: 76. 14 Ibid: 77. 15 D.S. Davis. Genetic Dilemmas and the Child’s Right to an Open Future. Hastings Cent Rep 1997; 27: 7–15. 16 D.S. Davis. The Parental Investment Factor and the Child’s Right to an Open Future. Hastings Cent Rep 2009; 39: 24–27.

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‘closing’ this future to a considerable extent. This is not to say that these examples would survive a detailed analysis, but they could explain why people believe that the argument from the right to an open future can be successfully applied to the question of whether we are allowed to enhance children or not. Jonathan Glover also mentions the right to an open future in the context of genetic engineering as a form of human enhancement: There is a question as to whether knowing our genes were the result of parental choice would make us feel any less the authors of our own life history than knowing that our genes are the product of the natural lottery. In neither case did we have any say in what they are. But it is true that too much genetic intervention might make us feel ourselves mere puppets of our parents and the technology they had at their disposal. But several values are at stake and the importance of independence from parents is not an absolute.17 According to Glover, the argument from the right to an open future is not a decisive one but just one argument among others. Nonetheless, he includes it in the group of arguments that are applicable to the case of human enhancement and, therefore, deserve consideration. Finally, Matteo Mameli18 criticizes the argument from the right to an open future when applied to the case of genetic engineering, not in principle but for reasons of plausibility. He does not reject the assumption that this argument is applicable to genetic engineering, which is why he, as an opponent of the argument, still takes it seriously. The main idea of the argument from human nature is that human beings possess a certain nature and that this nature is valuable. Francis Fukuyama defines ‘human nature’ as follows: ‘human nature is the sum of the behaviour and characteristics that are typical of the human species, arising from genetic rather than environmental factors’.19 The reason why Fukuyama regards human nature as valuable is that, according to him, it is the foundation of human dignity as a unique moral status: If what gives us dignity and a moral status higher than that of other living creatures is related to the fact that we are complex wholes rather than the sum of simple parts, then it is clear that there is no simple answer to the question, What is Factor X? That is, Factor X cannot be reduced to the possession of moral choice, or reason, or language, or sociability, or sentience, or

emotions, or consciousness, or any other quality that has been put forth as a ground for human dignity. It is all of these qualities coming together in a human whole that make up Factor X. Every member of the human species possesses a genetic endowment that allows him or her to become a whole human being, an endowment that distinguishes a human in essence from other types of creatures.20 ‘Factor X’ is just another expression for ‘human nature’, and Fukuyama believes that we as humans possess dignity in virtue of our genetic endowment and our characteristics that, in this unique combination, are the result of this endowment. This conception of human nature and human dignity suggests an argument from human nature against genetic engineering and other forms of human enhancement: if human nature is the foundation of human dignity as a moral status, then altering human nature should not be allowed, inasmuch as it would be a serious threat to human dignity. Since human dignity is the highest moral status a being can probably achieve, we are well advised not to meddle with our genetic or biological properties. Enhancing children would constitute an inexcusable violation of their dignity because children are more defenceless than adults and because the natural relationship between children and adults is that the latter protect the former instead of threatening their moral status. Being another proponent of the argument from human nature, the President’s Council on Bioethics21 suggests that human beings have a natural form of agency and that using enhancement technologies would be incompatible with this form of agency, thereby undermining our dignity. The argument from human nature is challenged by others,22 which is why we are justified to consider it as an ethically relevant argument instead of a mere expression of personal concerns. One should note that the interpretations of human nature and human dignity advanced by Fukuyama and the President’s Council on Bioethics can be criticized as inadequate and replaced by other interpretations. An alternative, Kantian interpretation of human dignity could regard it as intertwined with personal autonomy,23 so that any violation of a person’s autonomy has to be equated with a violation of this person’s dignity. If personal autonomy is seen as a central component of human nature, one could still try to apply the argument from human nature to the enhancement of children. Yet the interpretations of Fukuyama and the President’s Council 20

17

J. Glover. Choosing Children. Genes, Disability, and Design. Oxford/ New York: Oxford University Press; 2006. p. 72. 18 M. Mameli. Reproductive Cloning, Genetic Engineering and the Autonomy of the Child: the Moral Agent and the Open Future. J Med Ethics 2007; 33: 87–93. 19 Fukuyama, op. cit. note 6, p. 130.

Ibid: 171. The President’s Council on Bioethics, op. cit. note 3, p. 292. 22 A. Buchanan. Human Nature and Enhancement. Bioeth. 2009; 23: 141–150; T. McConnell. Genetic Enhancement, Human Nature, and Rights. J Med Philos 2010; 35: 415–428. 23 G. Hottois. A Philosophical and Critical Analysis of the European Convention of Bioethics. J Med Philos 2000; 25: 133–146: 137–138. 21

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The Enhancement of Children versus Circumcision on Bioethics appear to be better suited for an application to the enhancement of children because most enhancement technologies can be expected to increase personal autonomy and not to decrease it. One might argue that enhancement technologies could foreclose certain options a child would have been able to pursue had those technologies not been applied, for example, by pushing the child into a particular direction of life choices, but this reasoning collapses into an argument based on the right to an open future instead of being a genuine argument from human nature anymore. Furthermore, by enabling a child to pursue other options, enhancement technologies could still constitute a net increase of this child’s autonomy, namely, as long as these other options outnumber those ones the child will not be able to pursue anymore. This alternative interpretation of human nature and human dignity, therefore, renders the argument from human nature less applicable to the enhancement of children, but this does not constitute a threat to the general reasoning in this article. For I do not attempt to demonstrate that the argument of human nature is applicable to the enhancement of children under every interpretation, but that if it is applicable under fairly common interpretations like those favoured by Fukuyama or the President’s Council on Bioethics, then it is also applicable to circumcision.

APPLYING THE ARGUMENTS TO CIRCUMCISION We have good reasons to believe that the argument from insecurity can also be applied to circumcision, although one should be careful not to overstate the risks or the chances of this procedure, respectively, unless sufficient empirical data is available.24 What we do know, however, is that circumcision can be linked to sexual dysfunction although it does not necessarily have to result in sexual dysfunction.25 Yet a recent systematic review of studies on the effects of circumcision on sexual function suggests that these effects are not negative and that studies reporting negative effects contain various flaws.26 Given these findings, it seems premature to claim that circumcised children are at risk of experiencing less intense sexual pleasure as adults. One also has to recognize the risks of 24

D. Benatar. Evaluations of Circumcision Should Circumscribed by the Evidence. J Med Ethics 2013; 39: 431–432. 25 D. Bollinger & R.S. Van Howe. Alexithymia and Circumcision Trauma: a Preliminary Investigation. Int J Mens Health 2011; 10: 184– 195; P.M. Fleiss. The Case against Circumcision. Mothering: The Magazine of Natural Family Living 1997; Winter: 36–45. 26 B.J. Morris & J.N. Krieger. Does Male Circumcision Affect Sexual Function, Sensitivity, or Satisfaction? – A Systematic Review. J Sex Med 2013; 10: 2644–2657.

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circumcision imposed on the neonate or infant, even though they might be comparably low27 and, as one should admit, could also be used for arguing against other practices, such as ear piercing.28 On the other hand, circumcision could also decrease the risk of contracting HIV29 or other diseases.30 As these observations show, circumcision can count as an insecure procedure inasmuch as it benefits people by decreasing the risk of contracting diseases but could also hold undesirable side effects, such as sexual dysfunctions, severe bleeding, or the contraction of the herpes simplex virus through the Jewish practice of metztitzah b’peh, where the mohel, a ritual circumciser, touches the wound of the infant with his lips in order to remove the blood.31 The problem related to this kind of insecurity is that it does not allow policymakers to arrive at truly informed decisions on whether to allow circumcision, restrict it to specific cases, or prohibit it entirely. A total prohibition of circumcision appears to be unjustified because it would deprive parents of the possibility of providing their children with a protection (although not total) against various diseases. Moreover, a total prohibition might create a ‘black market’, so that a focus on harm reduction could be a more advisable focus.32 On the other hand, since the wellbeing of children is at stake, the risks involved in circumcision should not be ignored but should be taken into account in any process of policy development. As one can see, insecurity is truly an important factor in the debate about circumcision, so that the argument from insecurity has a solid foundation. It is applicable to the case of circumcision although it cannot be used for arriving at a decisive conclusion. The argument from the right to an open future is directly applied to circumcision by Robert J. L. Darby,33 who compares circumcision with deliberately creating a deaf child. Both procedures are actions towards a child 27 J.M. Hutson. Circumcision: a Surgeon’s Perspective. J Med Ethics 2004; 30: 238–240. 28 S. Holm. Irreversible Bodily Interventions in Children. J Med Ethics 2004; 30: 237. 29 B. Auvert et al. Randomized, Controlled Intervention Trial of Male Circumcision for Reduction of HIV Infection Risk: the ANRS 1265 Trial. PLoS Med 2005; 2: 1112–1122; R.C. Bailey et al. Male Circumcision for HIV Prevention in Young Men in Kisumu, Kenya: a Randomised Controlled Trial. Lancet. 2007; 369: 643–656; R.H. Gray. Male Circumcision for HIV Prevention in Men in Rakai, Uganda: a Randomised Trial. Lancet 2007; 369: 657–666. 30 Hutson, op. cit. note 27. 31 D.S. Davis. Ancient Rites and New Laws: How Should We Regulate Religious Circumcision of Minors? J Med Ethics 2013; 39: 456–458. 32 J. Savulescu. Male Circumcision and the Enhancement Debate: Harm Reduction, Not Prohibition. J Med Ethics 2013; 39: 416–417: 416. 33 R.J.L. Darby. The Child’s Right to an Open Future: Is the Principle Applicable to Non-Therapeutic Circumcision? J Med Ethics 2013; 39: 463–468.

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who cannot express any preferences and whose possible future preferences are not taken into account. The upshot of applying the argument from the right to an open future to circumcision is the following rule: ‘Whenever a child is too young to express preferences, the imperative is to refrain from actions that unnecessarily and irreversibly close off options.’34 Giving a child the opportunity to live with a foreskin instead of removing it irreversibly is the only feasible way of conforming to this rule. Darby recommends: ‘Respect for the open future principle thus requires parents to leave their boys’ foreskins alone and let them make up their own minds about such an intimate personal choice when they reach the age of consent.’35 In his article, Darby cites several studies suggesting that the loss of one’s foreskin implies the loss of valuable sexual experiences and, therefore, should be regarded as a harm. In a drastic statement, he draws the following analogy: ‘Circumcision is analogous to smoking, eating junk food and not cleaning one’s teeth because it causes long-term harm to the body and reduces its future functionality.’36 If we assume that this analogy is plausible, the argument from the right to an open future is a strong objection to circumcision because it requires from parents not only that they ensure an open future for their children but that they ensure a less harmful future for them. Yet even if this analogy were implausible, for example, because circumcision had some negative, but also some positive effects, or because it were difficult to empirically establish a robust relation between circumcision and negative effects, the argument from the right to an open future would still be applicable. A child could develop the preference to live with a foreskin and to deliberately reject the positive effects of circumcision, and another child could develop the preference for circumcision although this would imply experiencing some positive effects while also making some negative experiences. Adherence to the recommendation given by the argument from the right to an open future is the only way of ensuring that the child can live in accordance with its own future preferences. One can even make the case that this right corresponds to the obligation of parents to protect the bodily properties of their children against interventions like circumcision.37 Finally, the argument from human nature is also applicable to circumcision. Human boys are not born circumcised since they possess a foreskin. Consequently, a circumcised penis is unnatural or artificial inasmuch as it requires human intervention in order to carry out a circumcision and to create a circumcised penis. The ques34

Ibid: 466. Ibid: 467. 36 Ibid. 37 R.S. Van Howe. Infant Circumcision: the Last Stand for the Dead Dogma of Parental (Sovereignal) Rights. J Med Ethics 2013; 39: 475– 481. 35

tion remains, though, whether a circumcision is an intervention that alters the nature of children on whom it is performed in an ethically contentious way. Maybe circumcision is on par with other interventions that alter the nature of humans but are usually regarded as permissible or even recommended or obligatory, such as vaccination. Although having an intact foreskin might be no property featuring on a list of properties that constitute human nature, such as the qualities making up Francis Fukuyama’s Factor X, one should not forget that a foreskin is not just some random kind of skin. It is a part of the sexual organ of men, and removing it can result in sexual dysfunctions and a decreased ability to procreate. However, intentionally applying a procedure to a neonate or an infant that could produce these results should at least count as a way of deliberately disrespecting its human nature and, possibly, its dignity as well. For, since procreation is widely regarded as one of the most important things providing a life with meaning and since parenthood is regarded as a paramount aim by many people, meddling with a foreskin for non-medical reasons is equivalent to meddling with a potential major source of meaning and happiness in another person’s life. Even if one does not accept this line of thought, there is another reason why the argument from human nature is applicable to circumcision: this procedure violates the bodily integrity of a child or, in order words, constitutes a permanent and intentional alteration of the child’s physical shape for non-medical reasons and without its explicit consent. This can also be reasonably interpreted as an alteration of its nature and a violation of its dignity.38

AVOIDING INCONSISTENCIES As we have seen, three main arguments against the enhancement of children are also applicable to circumcision. Both procedures can be regarded as insecure to a certain degree, might constitute a violation of the child’s right to an open future, and alter its nature, which could be interpreted as a violation of its dignity. While it may be possible that there are arguments speaking for the enhancement of children or circumcision, respectively, that outweigh the arguments discussed above, we can tentatively conclude that whoever rejects the enhancement of children because of these arguments should reject circumcision for the same reason. A person who rejects the former for this reason but accepts the latter holds inconsistent moral beliefs. Legal restrictions on the enhancement of children by one legislative body 38

R. Merkel & H. Putzke. After Cologne: Male Circumcision and the Law. Parental Right, Religious Liberty or Criminal Assault? J Med Ethics 2013; 39: 444–449: 445.

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The Enhancement of Children versus Circumcision combined with a lack of legal restrictions on circumcision by the same body would be equally inconsistent. So, how can one avoid being inconsistent? I will now discuss and evaluate three strategies of avoidance before arriving at a conclusion. A first strategy could be to point out that there are fundamental differences between the enhancement of children and circumcision, so that one can apply the arguments to enhancement but not to circumcision. Let us call this strategy the ‘fundamental differences strategy’. Proponents of the fundamental differences strategy could argue that one can reject the enhancement of children while accepting circumcision without holding inconsistent moral beliefs or advocating inconsistent policies. One fundamental difference between enhancement and circumcision could be that the former is much more radical than the latter. This higher degree of radicality could also have an impact on the applicability of the arguments. It might be justified to reject an unnatural and insecure intervention that violates a child’s right to an open future and is much more radical than an intervention that can also be qualified like this but has a much lower degree of radicality, such as circumcision. A further difference could be the intentions behind the enhancement of children and circumcision, respectively. While the intention of parents who enhance their children is primarily to apply a procedure that will benefit them physically or mentally, the intention of parents who let their children be circumcised for non-medical reasons is to live in accordance with the demands of their religion or with a socially established practice. One could argue that this difference can justify a rejection of the enhancement of children and a simultaneous acceptance of circumcision because the former would be a eugenic practice39 whereas the latter would merely constitute a widely accepted religious ritual or social practice. However, I believe that the fundamental differences strategy is flawed and should be rejected: first of all, one has to ask what is meant by ‘radical’ when this predicate is applied to human enhancement and circumcision, respectively. The permanent and irreversible removal of the foreskin appears not to be less radical than a form of enhancement of children that is widely accepted: vaccination. Since vaccination can at best be regarded as a kind of ‘pre-emptive therapy’ against a disease a child might eventually contract, it should rather be regarded as a commonly accepted form of enhancement40 because it clearly has a beneficial effect on the child’s immune 39

R. Sparrow. In vitro Eugenics. J Med Ethics. 2013; doi: 10.1136/ medethics-2012-101200; R. Sparrow. A Not-So-New Eugenics. Harris and Savulescu on Human Enhancement. Hastings Cent Rep 2011; 41: 32–42. 40 See the discussions of the therapy-enhancement distinction in L. Colleton. The Elusive Line between Enhancement and Therapy and Its Effects on Health Care in the U.S. J Evol Technol 2008; 18: 70–78; D.B.

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system and endows the child with a new trait, namely, resistance against a specific disease it would not have otherwise. Although the effects of several vaccinations can last for decades, they are not as permanent as a circumcision, so that they can, in principle, be reversed if enough time passes. Furthermore, the effects of vaccination are invisible to others and even imperceptible by the child whereas the effects of a circumcision are certainly perceptible. In this sense, vaccination as an enhancement is much less radical than circumcision. One could try to advance another understanding of radicality that refers to the ‘depth’ of an intervention to be a central criterion for determining whether it is more or less radical. Yet I do not believe that this strategy will hold promising results because it would primarily lead to a debate about the precise meaning of ‘depth’ in this context. The attempt to base the fundamental differences strategy on the parents’ intentions also remains unconvincing: the intention to carry out a certain procedure is no property of the procedure itself but merely a property of the person who carries it out or advises others to carry it out. While one can refer to the intentions of parents who ask for their child to be circumcised in order to justify the circumcision, this strategy cannot be used to establish a difference between the enhancement of children and circumcision per se. We can conclude that proponents of the fundamental differences strategy have to find differences that are not ambiguous, like radicality, and are in fact differences of the interventions themselves, instead of those who wish to let them be carried out, such as intentions. Unless they are unable to argue for the existence of such differences, this strategy fails and should not be used for arguing that one can reject the enhancement of children and accept circumcision. The second strategy, the ‘total prohibition strategy’ would be to bluntly accept the line of thought presented in the previous sections of this article and to reject the enhancement of children as well as circumcision. This could imply that one merely holds the private conviction that both procedures are ethically impermissible, but it could also imply that one advocates legal actions against them. Yet this strategy appears not to be feasible because, as we said earlier, a total prohibition of circumcision would likely create a ‘black market’41 and because it could create a slippery slope towards the prohibition of enhancement not only in the case of children but also in the case of adults. We do not wish to create a black market for circumcision because this black market would not be under any governmental control, so that it would be extremely Resnik. The Moral Significance of the Therapy-Enhancement Distinction in Human Genetics. Camb Q Healthc Ethics 2000; 9: 365–377. 41 Savulescu, op. cit. note 32.

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difficult to ensure that circumcisions performed under the rules of this black market meet certain standards of safety. A prohibition of circumcision for the sake of children’s well-being might lower the total numbers of circumcisions, but it might also increase the risks for those children whose parents seek the service on a black market, which is certainly not intended by proponents of the total prohibition strategy. Although slippery slope arguments are notoriously problematic because they have to rely on speculation to some extent, one can advance a defensible slippery slope argument against the total prohibition strategy in the case of the enhancement of children: this prohibition could be the starting point for further prohibitions of voluntary enhancement of adults. Only one of the arguments discussed above is exclusively applicable to the enhancement of children, namely, the argument from the right to an open future. The other arguments can be used as objections to human enhancement in general, so that opponents of human enhancement in general could use a prohibition of the enhancement of children to make their case stronger by referring to these remaining arguments. They could argue that not only the enhancement of children should be prohibited, since two of three arguments against it are also applicable to the enhancement of adults. However, since there are various specific enhancement technologies that are commonly accepted – think again of vaccination, but also of caffeine or testosterone used by amateur athletes in non-competitive disciplines – the total prohibition strategy could, by a slippery slope, hold highly counterintuitive results that might not even be intended by its proponents. They would also face serious objections because there is a wide range of arguments for human enhancement in general although discussing them goes well beyond the scope of this article. The total prohibition strategy, therefore, might appear to pay respect to the right of children to decide for themselves and their bodily properties to a large extent. It would, for example, be adopted by liberally-minded people who wish to defend this right. However, this strategy could also lead to unintended side effects by creating a black market in the case of circumcision and by being adopted by less liberally-minded people who wish to prohibit human enhancement altogether. We should look for another strategy that avoids the inconsistencies mentioned initially and such undesirable consequences as well. I believe that the ‘subsumption strategy’ deserves a closer analysis: according to this strategy, circumcision can be subsumed under human enhancement, so that we can and should treat it accordingly for conceptual reasons. If circumcision is nothing but a special case of enhancement, it is almost trivial that the arguments working against the enhancement of children also work against circumcision. Furthermore, while the three argu-

ments discussed above are applicable to enhancement of children and circumcision, other arguments for or against human enhancement in general appear applicable, at least in principle, to circumcision in particular, when one pursues the subsumption strategy. This does not imply that every argument discussed in the debate about human enhancement will turn out to be a valuable contribution to an ethical analysis of circumcision since this is still a special case. However, one should be prepared for arguments that are usually not associated with circumcision to be advanced for or against this procedure. It is not obvious that circumcision is a special kind of enhancement, but one can give reasons that speak for the plausibility of the subsumption strategy. As discussed above, circumcision may have positive as well as negative effects on the child to whom the procedure is applied and on the later adult.42 Given this state of epistemic uncertainty, circumcision could either count as an enhancement – if the benefits outweigh the risks – or not – if the risks outweigh the benefits. Since the risks of circumcision can mostly be avoided if one adheres to certain standards of medicine and hygiene,43 one can assume that the benefits outweigh the risks in usual cases, though this assessment should not be generalized. Its correctness also depends on the correctness of empirical studies on the effects of circumcision on sexual function and on the risk of contracting sexually transmitted diseases like HIV. Therefore, subsuming circumcision under enhancement appears to be a plausible strategy, but we should be prepared to correct this assessment as soon as our current knowledge of the risks and benefits of circumcision is revealed to be outdated. Treating circumcision as a form of human enhancement implies that its sole purpose should be to benefit the person who is circumcised. Proponents of human enhancement believe that the aim of enhancing the traits of a person is to increase this person’s well-being, so that it is unacceptable to apply enhancement technologies to a person for ideological or other intentions that do not focus on this person’s well-being. Consequently, ideological or other intentions that do not focus on the well-being of children who are about to be circumcised should be rejected because they are insufficient justifications for circumcision. These intentions include religious ones, such as circumcision being a necessary prerequisite to belong to a certain religion or being a sign of obedience towards a supreme being. There may still be a strong political motivation to allow circumcision for religious intentions, but if one pursues the subsumption strategy, one is inclined to the view that, ethically speaking, circumcision for religious intentions is unacceptable.

42 43

See the discussion of notes 24–31. Savulescu, op. cit. note 32.

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The Enhancement of Children versus Circumcision But should we not ignore the intentions of parents who wish to let their child be circumcised as long as there is sufficient evidence suggesting benefits for the child, such as a decreased probability of contracting certain diseases? One could argue that these intentions do not matter because the child will gain the benefits of being circumcised regardless of the intentions of its parents. Yet, as we already know, they can make a difference with respect to the method of circumcision: the metztitzah b’peh ritual endangers the child because it could contract the herpes simplex virus from the circumciser. Since this ritual will only be performed in a religiously motivated circumcision, the intentions of the parents can have a direct influence on the risks for the child. Therefore, it is possible that the child gains the benefits of a circumcision but is not exposed to risks like these if the circumcision is carried out for non-religious intentions. There is a further reason why we should not ignore the intentions: religious rituals and socially established practices are based on traditions, and although these rituals or practices can and do change over time – a circumcision as it is performed today is certainly safer than a circumcision performed in a culture with lower medical and hygienic standards – it is nonetheless unlikely that devout followers of a religion will abolish these rituals altogether if they are asked to. Parents living in an environment that encourages circumcisions because it is a socially established practice are likely to exhibit a similar behaviour. However, it is imaginable that children can gain the benefits offered by circumcision without being exposed to its risks, for example, if researchers are able to develop treatments against diseases against which circumcision offers an increased protection. These treatments would make circumcision entirely useless as an enhancement. It would merely be a cosmetic intervention for men who, voluntarily, undergo this procedure because they want their penis to have a particular shape. The subsumption strategy therefore implies that circumcision might eventually suffer the same fate as other enhancement procedures: it could become more and more outdated because other procedures promise similar benefits but at a decreased rate of risk. Consequently, parents should be discouraged as soon as such procedures are available and feasible. While religious or social intentions for circumcision might be tolerable today, at least if they do not require dangerous rituals like the metztitzah b’peh, because the child could benefit from a circumcision regardless of these intentions, they could become less tolerable in the

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future, when less risky and more secure replacements for circumcision are available.

CONCLUSION Three major arguments against the enhancement of children are also applicable to circumcision, so that it is difficult to reject the former on this basis while accepting the latter. Two strategies for avoiding this inconsistency appear not to be promising, but a third strategy, the subsumption strategy, can be defended: according to this strategy, circumcision can be subsumed under human enhancement and should be treated accordingly. We know of enhancement technologies whose use is widely accepted, and, given its current legal and social status, circumcision could also be regarded as one of these technologies. However, enhancement technologies can become outdated by being replaced by safer or more efficient products, and there are good reasons not to use an outdated enhancement technology anymore. If one pursues the subsumption strategy, one has to accept that circumcision could face the same fate in the future: as soon as interventions are available that hold the same benefits as circumcision but avoid the risks posed by it, circumcision should be regarded as an outdated enhancement technology and should be treated accordingly. This implies that, as things stand today, a legal prohibition of circumcision is not justified, but restrictions that focus on risk reduction are acceptable. Yet the subsumption strategy also implies that this does not have to be an everlasting state of affairs because a prohibition of circumcision as an eventually outdated enhancement technology is within the range of defensible positions. Furthermore, one can imagine the institutional advocacy of alternatives to circumcision as soon as these alternatives exist. This would be a compromise between permission and prohibition that would also be justified by the subsumption strategy. Acknowledgments I wish to thank two anonymous reviewers for their comments that helped me to improve the reasoning in this article. Tobias Hainz is a postdoctoral research fellow at Hannover Medical School (Germany), Institute for History, Ethics, and Philosophy of Medicine. His primary research interests include the ethics of emerging and future technologies, especially human enhancement and life extension technologies, and philosophical aspects of public involvement in biomedical research and innovation.