Clinical Ethics in Anesthesiology. A Case-Based Textbook

1.Consent and refusal

12. Consent and cultural conflicts: ethical issues in pediatric anesthesiologists' participation in female genital cutting

Maliha A. Darugar, Rebecca M. Harris and Joel E. Frader

The Case

A healthy 5-year-old female patient is scheduled for “surgical correction of clitoral phimosis.” The patient’s Somali parents explain their custom of “circumcising” girls; a surgeon has agreed to perform the procedure. The anesthesiologist doubts the medical indications for the procedure. The parents assert the need to circumcise their daughter so she will be accepted in their community. They tell the anesthesiologist that if they cannot find a US physician to perform the procedure, they will go to Somalia where a village elder will do it, without benefit of anesthesia or aseptic conditions.

Female genital cutting (FGC) refers to procedures involving partial or total removal of external genitalia or other alteration of female genitals for nonmedical reasons. The World Health Organization (WHO) defines four types of FGC.1 Type I (clitoridectomy) involves partial or total removal of the clitoris and/or the prepuce. Type II (excision) involves partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora. Type III (infibulation) involves cutting and appositioning the labia minora and/or the labia majora to create a covering seal narrowing the vaginal orifice. Infibulation may or may not involve excision of the clitoris. Type IV involves all other procedures to the female genitalia for nonmedical purposes, including pricking, piercing, incising, scraping, or cauterization. Despite this categorization, significant overlap and ambiguity exist in the practice within and between the cultures that practice it. The procedure is most often performed between birth and 15 years of age, depending on tribal or regional custom. Adults occasionally undergo the procedure for the first time or request reinfibulation after childbirth.

Many different terms have been used to describe FGC, including female genital mutilation, female genital cutting/mutilation, and female circumcision, with continued debate about the best term. Some object to “circumcision’ as suggesting an inaccurate parallel with male circumcision. The WHO adopted female genital mutilation as the term for this practice.1 However, many researchers believe “mutilation” alienates the cultures practicing it, resulting in unproductive backlash. We use FGC as descriptive and as distinguished from male circumcision, while withholding judgment about the practice.

FGC is prevalent globally and not limited to any religious or ethnic group. Its highest prevalence occurs in western and eastern Africa where an estimated 90%–100% of females undergo some form of the practice in Egypt, Guinea, Mali, Somalia, and northern Sudan. Between 100 and 140 million girls and women have experienced FCG worldwide and three million girls may undergo the practice each year.1 In an effort to preserve ethnic identity, immigrants from these countries have brought the practice to the West, including Europe and the US. Thus, first world physicians can no longer regard FGC as exotic and must confront requests for participation, especially where large concentrations of immigrants regard FGC as expected and routine.

FGC is deeply entrenched in cultures that practice it and persists despite large-scale international campaigns, including medical and health organizations condemning it. The WHO, the American Medical Association (AMA) and the International Federation of Gynecology and Obstetrics (FIGO) all oppose the practice and urge health professionals to abstain from participating. Ten international health and human rights organizations have created a consensus statement summarizing the international fight to end FGC.2

Commentators and analysts differ regarding the underlying influences promoting FGC. Many believe that patrilineal social, economic, and political values drive the practice of FGC. Some anthropologists think that women perpetuate the practice as a form of African cultural rebellion against encroaching Western societies. From the latter perspective, FGC has virtue, promoting female empowerment, strength, cleanliness, and purity. While some assert that FGC follows Islamic principles, the practice predates the beginning of Islam, is not practiced by the majority of Muslims, and is not universally endorsed by Islamic scholars and theologians. Some supporters believe FGC curbs sexual desire in women, preserving virginity prior to marriage.3 Others consider FGC to enhance the appearance of female genitalia. Many women consider FGC part of a coming-of-age ritual inducting young girls as members of a community. In any case, women who reject the practice endure stigmatization and ostracism. Females without FGC are often considered unsuitable for marriage within their community, creating practical dilemmas, as marriage grounds economic and social stability. All of these factors contribute to perpetuating FGC.3

Community elders and birth attendants traditionally performed FGC. Campaigns from the West highlighting severe medical consequences of FGC performed under unhygienic conditions have backfired. Rather than halting the procedure, the efforts have shifted the practice to the medical sector. Women from cultures practicing FGC now ask physicians from many specialties, including obstetrics/gynecology, surgery, and family practice, to perform the procedure using sterile technique with analgesic agents to minimize pain and adverse medical outcomes.

Patients or other medical professionals may request the help of anesthesiologists for female genital surgeries. This may put an anesthesiologist in a difficult position, as s/he must consider the patients’ wishes, the professional’s relationships with and obligations to other members of the medical team, and the ethical implications of participating in a procedure with a cultural, rather than medical, justification.

Medical sequelae of FGC

Physicians must understand the potential medical sequelae of FGC to make reasoned decisions about whether or not to participate in the procedure. Both immediate and long-term medical complications arise from FGC. Most of the immediate adverse outcomes result from nonhygienic practices outside of medical settings by lay midwives or shamans. Some of the long-term consequences occur regardless of the conditions under which the cutting occurred.

Immediate adverse outcomes of FGC include pain, post-operative infection, shock, tetanus, hemorrhage, and death. Long-term physical complications include urinary problems, dysmenorrhea, inflammation, keloids, introital and vaginal stenosis, painful vulvar masses, and fistulae. Long-term sexual dysfunction includes dyspareunia, loss of libido, inability to achieve orgasm, and partner dissatisfaction. Adult women may require defibulation procedures to allow for intercourse and childbirth. Subsequent obstetric complications include prolonged labor from mechanical obstruction, hemorrhage from perineal tears, and perinatal complications including fetal death. Studies suggest FGC can increase the risk of human immunodeficiency virus (HIV) infection from unsterilized instruments.4

No literature demonstrates specific health benefits of FGC, though no well-controlled, unbiased studies consistently show the physical harms of FGC. Existing studies do not adequately distinguish the adverse consequences associated with subtypes of FGC. A systemic review of the adverse consequences of FGC concluded that most studies had inadequate power or failed to show statistically significant increased risk of many complications, including urinary problems and infertility among women with FGC compared to uncut women. Data do not unequivocally demonstrate differences in frequency of intercourse, orgasm, and sexual desire in women who have undergone FGC compared to women who have not. Finally, the psychosocial and cultural value of the practice to women who practice it cannot be readily tallied.

Ethical issues

Whether an anesthesiologist should participate in FGC depends on his or her interpretation of ethical considerations. Primary among these is the weight to give cultural values, beliefs, and practices of a particular community, compared with claims of universal human rights, a concept known as cultural or moral relativity. Should Western concerns about gender equality, treatment of children as a protected vulnerable group, patient autonomy, avoiding paternalism, the need to stress nonmaleficence (prevention of harm), and the primacy of beneficence trump an ethnic or other community’s belief that FGC preserves important and valid traditions?

Cultural/moral relativism

Cultural or moral relativism refers to the notion that moral or ethical norms must be understood in the context of particular circumstances rather than as universal moral standards. A cultural/moral relativist may argue that Westerners have no moral authority over those practicing FGC. The relativist would note widespread variation in what communities consider acceptable human activity, for example, polygamy vs. monogamy, proscriptions on vs. permissibility of pregnancy termination, allowing or prohibiting physical punishment for civil transgressions and so on, as well as a lack of a generally agreed upon system for resolving philosophical disputes. Others support a notion of universal, absolute human rights. From this perspective all humans have a right to live free of institutionalized suffering, meaning that policies or practices that systematically promote harms to a group of people are unethical. Further, minority and/or politically and economically marginalized persons deserve protection from injustice. Some see FGC as part of a long-practiced set of honored traditions that are common and widely accepted in Somalia. Others condemn FGC as unethical in the US as imposing physical and sexual harm on girls and women, perpetuating a social system that oppresses and disenfranchises females.

Human rights, children’s rights and gender equality

Physicians must balance their duty to respect patient, or in the case of children, parental autonomy with their duty to respect and protect human rights. FGC challenges women’s rights to gender equality and the WHO considers FGC a violation of women’s rights. FGC also violates the rights of children in the view of many nongovernmental organizations such as Amnesty International and UNICEF, necessitating action to protect especially vulnerable young girls.

The United Nations Declaration on the Elimination of Violence Against Women classifies FGC as a type of violence against women, impinging on a woman’s right to, “equality, security, liberty, integrity and dignity.”5 Proponents of FGC defend the custom as parallel to male circumcision. Some consider prohibition of FGC as a violation of equal rights in that it prevents women from participating in a custom in which men participate. However, women do not experience health benefits from FGC that parallel males benefits from circumcision (e.g., reducing HIV transmission); the adverse health effects of FGC have no similar set of poor outcomes for males who have penile circumcision. Furthermore, harms to women from FGC stem from more than the medical consequences of the procedure; any violation of rights is embedded in broad social structures supporting and perpetuating FGC, including male supremacy in education, political freedom, and economic opportunity. In this light, physician participation in FGC, while possibly reducing harm to the individual patient, legitimizes the practice as medically and socially acceptable, maintaining gender inequalities.

Medical decisions involving children have unique ethical considerations. The American Academy of Pediatrics Committee on Bioethics advises that children should be given age-appropriate information about medical decisions and the opportunity to provide assent for medical interventions.6 Children also have a right to dissent to medical interventions when not urgently necessary to preserve the health or wellbeing of the child. FGC is a non-urgent procedure that has significant risks. The child will have to live with any complications or consequences of the procedure. Under such circumstances, the informed child should have the right to refuse the procedure and physicians should respect this right. When a young child does not have the capacity to make decisions about her medical care, the parents must make medical decisions according to the best interest of the child. In FGC, parents typically request the procedure on the grounds that FGC will preserves the girl’s chances of obtaining a good marriage. Whether such social interests outweigh the medical and psychological harms of the practice comprises the ethical problem in FGC. Physicians have independent moral responsibilities toward their child patients and cannot rely solely on the views of parents. The risks and benefits (including the socio-cultural benefits) specifically for the child deserve careful consideration before physicians decide whether to participate in FGC.

Patient autonomy, conscientious objection, and paternalism

Patient autonomy is a fundamental principle of bioethics, underlying patients’ rights to make informed and voluntary decisions about their medical care. It does not, however, mean that patients must receive any requested medical intervention. Two broad types of intervention that patients do not have an unequivocal right to receive from a given physician include: (a) interventions without medical indications and (b) interventions that violate the physician’s ethics. In the former case, one often finds dispute about what constitutes a medical indication. For example, some individuals may feel, and courts have upheld, the right of a parent to request and receive mechanical ventilation for recurrent apnea in an infant with anencephaly despite medical claims that artificial respiration served no medical purpose. In the latter case, individual physicians may decline participation in pregnancy termination, removal of feeding tubes, or palliative sedation, though they may have obligations to explain legally available options and refer patients or families to other professionals willing and able to provide the requested service.

Of course, medical professionals routinely perform procedures without clear medical necessity, such as cosmetic surgery. Assuming an informed patient with adequate capacity to consent, FGC seems similar to elective female genital cosmetic surgery: no medical indication exists and each alters the shape of the genitals. Just as women request labiaplasty and vaginoplasty to alter their bodies to meet Western standards of beauty, women requesting FGC aim to meet cultural standards of beauty and gain social acceptance. The interventions may differ, however, with respect to the likelihood of negative consequences, such as diminished sexual pleasure, risk of fistula formation, and complications of pregnancy, labor, and delivery.

Highly contentious procedures like FGC can challenge physicians’ values to the extent that they feel they cannot reconcile participation and must refrain from any involvement. Conscientious objection involves the refusal to participate in activities on religious, moral, or ethical grounds. Frader and Bosk argue that invoking conscientious objection for medical interventions acceptable to society and to the medical profession generally undermines patient autonomy, professional ethics, and trades on the imbalance of power in the patient-physician relationship.7 They oppose opting out of any interaction with the patient or surrogate about an objected-to intervention and suggest physicians must warn prospective patients or family members about their objections before solidifying a physician–patient relationship or explain the objections to those with an established relationship and provide appropriate referrals. In the case of FGC, assuming various forms of the practice remain legal, anesthesiologists may have to decide if they can ethically agree to participate despite their strong moral opposition. If the anesthesiologist or surgeon cannot find another anesthesiologist willing to provide the requested care, the anesthesiologist will face a dilemma. She or he must compromise personal values and provide the requested service or continue to refuse to participate. The latter decision implies a philosophically problematic belief that his or her values are “better” than those of the family and should prevail.

Nonmaleficence and beneficence

Although most professional and advocacy organizations in the West strongly condemn FGC, anesthesiologists may feel conflicted because patients may end up having it done in unsanitary nonmedical settings with inadequate analgesia. FGC performed in the hands of medical professionals can reduce harms by decreasing adverse outcomes through sterile technique, increasing the skill level of the cutter, and providing appropriate pre- and post-operative care. Medical FGC may allow professionals some control over the type and severity of procedure performed. However, FGC violates the principle of nonmaleficence, the duty to do no harm. Nevertheless, physician participation may promote beneficence by reducing the harm patients would otherwise suffer in untrained hands. The case exemplifies the complexity of medical decisions we cannot reduce simply to “do no harm.” The goal of harm reduction may override the physician’s duty to do no harm.

Case analysis

The anesthesiologist must consider the medical and social risks and benefits of FGC to the patient. If he or she chooses to participate, the child may experience long-term adverse outcomes associated with FGC. However, the anesthesiologist will help the child’s acceptance in her culture. The anesthesiologist must balance her or his feelings about the procedure with the parents’ authority to raise their children according to their beliefs.

If the physician chooses not to participate, the child may have much greater risk for long-term adverse outcomes when performed in Somalia. Furthermore, the child will likely suffer greater procedure-associated pain. However, the anesthesiologist will be refusing to participate in a procedure contributing to the oppression of women and the rights of women to control their own bodies. The anesthesiologist may have a right to refuse to participate if he or she feels that the procedure contravenes his or her moral standards.

Key points

• FGC has wide acceptance in many cultures across the globe despite gender-related and more general human rights concerns raised by the practice.

• FGC produces adverse health outcomes, especially those arising from performance of the procedures by non-medical professionals.

• Physician participation in FGC may prevent some health consequences but also perpetuates objectionable social practices.

• FGC is particularly problematic when it involves a request from a parent for the procedure on a child, who will have to live with the long-term consequences of FGC.

• While some medical organizations, e.g., the AMA, have created guidelines for FGC, most professional societies provide only guidance, without a binding effect on members.

• Physicians’ decisions to participate in FGC currently rely on personal judgments, weighing adverse medical and psychological consequences against potential cultural benefits and harms.

References

1 World Health Organization. (2009). Female Genital Mutilation. http://www.who.int/mediacentre/factsheets/fs241/en/.

2* United Nations Interagency Group. (2008). Eliminating Female Genital Mutilation. An Interagency Statement.www.unfpa.org/webdav/site/global/shared/documents/publications/2008/eliminating_fgm.pdf.

3* Nour NM. (2008). Female genital cutting: a persistent practice. Rev Obstet Gynecol1, 135–9.

4 Brewer, D.D.Potterat, J.J.Roberst, J.M. Jr., and Brody, S. (2007). Male and female circumcisn associated with prevalent HIV infection in virgins and adolescents in Kenya, Lesotho, and Tanzania.Ann Epidemiol17, 217–26.

5 United Nations General Assembly. Declaration on the Elimination of Violence against Women. 1993. http://www.un.org/documents/ga/res/48/a48r104.htm.

American Academy of Pediatrics Committee on Bioethics (1995). Informed consent, parental permission, and assent in pediatric practice. Pediatrics95, 314–17.

7 Frader, J. and Bosk, C.L. (2009). The personal is political, the professional is not: conscientious objection to obtaining/providing/acting on genetic information. Am J Med Genet C Semin Med Genet,151C(1), 62–7.

Further reading

Cantor, J.D. (2006). When an adult female seeks ritual genital alteration: ethics, law, and the parameters of participation. Plast Reconstr Surg117, 1158–64; discussion 1165–6.

Nour, N.M. (2004). Female genital cutting: clinical and cultural guidelines. Obstet Gynecol Surv59, 272–9.

Obermeyer, C.M. (2005). The consequences of female circumcision for health and sexuality: an update on the evidence. Cult Health Sex7, 443–61.

Schreiber, M.Schott, G.E.Rasher, W. and Bender, A.W. (2009). Legal aspects of ritual circumcision. Klin Padiatr221(7), 409–14

Serour, G. I. (2010). The issue of reinfibulation. Int J Gynaecol ObstetFeb 5 [epub ahead of print]