Skip to main content
PMC home page
Journal of Medical Ethics logoLink to Journal of Medical Ethics
. 2002 Feb;28(1):10–16. doi: 10.1136/jme.28.1.10

Prophylactic interventions on children: balancing human rights with public health

F Hodges 1, J Svoboda 1, R S Van Howe 1
PMCID: PMC1733522  PMID: 11834752

Abstract

Bioethics committees have issued guidelines that medical interventions should be permissible only in cases of clinically verifiable disease, deformity, or injury. Furthermore, once the existence of one or more of these requirements has been proven, the proposed therapeutic procedure must reasonably be expected to result in a net benefit to the patient. As an exception to this rule, some prophylactic interventions might be performed on individuals "in their best interests" or with the aim of averting an urgent and potentially calamitous public health danger. In order to invoke these exceptions, a stringent set of criteria must first be satisfied. Additionally, where the proposed prophylactic intervention is intended for children, who are unlikely to be able to provide a meaningfully informed consent, a heightened scrutiny of any such measures is required. We argue that children should not be subjected to prophylactic interventions "in their best interests" or for public health reasons when there exist effective and conservative alternative interventions, such as behavioural modification, that individuals could employ as competent adolescents or adults to avoid adverse health outcomes. Applying these criteria, we consider the specific examples of prophylactic mastectomy, immunisations, cosmetic ear surgery, and circumcision.

Full Text

The Full Text of this article is available as a PDF (123.0 KB).

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Birley H. D., Walker M. M., Luzzi G. A., Bell R., Taylor-Robinson D., Byrne M., Renton A. M. Clinical features and management of recurrent balanitis; association with atopy and genital washing. Genitourin Med. 1993 Oct;69(5):400–403. doi: 10.1136/sti.69.5.400. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Bonanni P., Bonaccorsi G. Vaccination against hepatitis B in health care workers. Vaccine. 2001 Mar 21;19(17-19):2389–2394. doi: 10.1016/s0264-410x(00)00460-6. [DOI] [PubMed] [Google Scholar]
  3. Cold C. J., Taylor J. R. The prepuce. BJU Int. 1999 Jan;83 (Suppl 1):34–44. doi: 10.1046/j.1464-410x.1999.0830s1034.x. [DOI] [PubMed] [Google Scholar]
  4. Diseker R. A., 3rd, Peterman T. A., Kamb M. L., Kent C., Zenilman J. M., Douglas J. M., Jr, Rhodes F., Iatesta M. Circumcision and STD in the United States: cross sectional and cohort analyses. Sex Transm Infect. 2000 Dec;76(6):474–479. doi: 10.1136/sti.76.6.474. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Fleiss P. M. Explanation for false-positive urine cultures obtained by bag technique. Arch Pediatr Adolesc Med. 1995 Sep;149(9):1041–1042. doi: 10.1001/archpedi.1995.02170220107022. [DOI] [PubMed] [Google Scholar]
  6. Fleiss P. M., Hodges F. M., Van Howe R. S. Immunological functions of the human prepuce. Sex Transm Infect. 1998 Oct;74(5):364–367. doi: 10.1136/sti.74.5.364. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Frisch M., Friis S., Kjaer S. K., Melbye M. Falling incidence of penis cancer in an uncircumcised population (Denmark 1943-90) BMJ. 1995 Dec 2;311(7018):1471–1471. doi: 10.1136/bmj.311.7018.1471. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Ganiats T. G., Humphrey J. B., Taras H. L., Kaplan R. M. Routine neonatal circumcision: a cost-utility analysis. Med Decis Making. 1991 Oct-Dec;11(4):282–293. doi: 10.1177/0272989X9101100406. [DOI] [PubMed] [Google Scholar]
  9. Grulich A. E., Hendry O., Clark E., Kippax S., Kaldor J. M. Circumcision and male-to-male sexual transmission of HIV. AIDS. 2001 Jun 15;15(9):1188–1189. doi: 10.1097/00002030-200106150-00020. [DOI] [PubMed] [Google Scholar]
  10. Hiltunen M., Lönnrot M., Hyöty H. Immunisation and type 1 diabetes mellitus: is there a link? Drug Saf. 1999 Mar;20(3):207–212. doi: 10.2165/00002018-199920030-00001. [DOI] [PubMed] [Google Scholar]
  11. Jones R. B. Parental consent to cosmetic facial surgery in Down's syndrome. J Med Ethics. 2000 Apr;26(2):101–102. doi: 10.1136/jme.26.2.101. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Jørgensen E. T., Svensson A. The treatment of phimosis in boys, with a potent topical steroid (clobetasol propionate 0.05%) cream. Acta Derm Venereol. 1993 Feb;73(1):55–56. doi: 10.2340/00015555735556. [DOI] [PubMed] [Google Scholar]
  13. Kaplan G. W. Complications of circumcision. Urol Clin North Am. 1983 Aug;10(3):543–549. [PubMed] [Google Scholar]
  14. Laumann E. O., Masi C. M., Zuckerman E. W. Circumcision in the United States. Prevalence, prophylactic effects, and sexual practice. JAMA. 1997 Apr 2;277(13):1052–1057. [PubMed] [Google Scholar]
  15. Lazar N. M., Greiner G. G., Robertson G., Singer P. A. Bioethics for clinicians: 5. Substitute decision-making. CMAJ. 1996 Nov 15;155(10):1435–1437. [PMC free article] [PubMed] [Google Scholar]
  16. Lebit Lynn E. Compelled medical procedures involving minors and incompetents and misapplication of the substituted judgment doctrine. J Law Health. 1992;7(1):107–130. [PubMed] [Google Scholar]
  17. Leris C., Mokbel K. The prevention of breast cancer: an overview. Curr Med Res Opin. 2001;16(4):252–257. doi: 10.1185/030079901750120187. [DOI] [PubMed] [Google Scholar]
  18. Lerman C., Hughes C., Croyle R. T., Main D., Durham C., Snyder C., Bonney A., Lynch J. F., Narod S. A., Lynch H. T. Prophylactic surgery decisions and surveillance practices one year following BRCA1/2 testing. Prev Med. 2000 Jul;31(1):75–80. doi: 10.1006/pmed.2000.0684. [DOI] [PubMed] [Google Scholar]
  19. Maden C., Sherman K. J., Beckmann A. M., Hislop T. G., Teh C. Z., Ashley R. L., Daling J. R. History of circumcision, medical conditions, and sexual activity and risk of penile cancer. J Natl Cancer Inst. 1993 Jan 6;85(1):19–24. doi: 10.1093/jnci/85.1.19. [DOI] [PubMed] [Google Scholar]
  20. Newman L. Despite efficacy of prophylactic mastectomy, procedure finds few enthusiasts. J Natl Cancer Inst. 2001 Mar 7;93(5):338–339. doi: 10.1093/jnci/93.5.338. [DOI] [PubMed] [Google Scholar]
  21. Pisacane A., Graziano L., Mazzarella G., Scarpellino B., Zona G. Breast-feeding and urinary tract infection. J Pediatr. 1992 Jan;120(1):87–89. doi: 10.1016/s0022-3476(05)80607-9. [DOI] [PubMed] [Google Scholar]
  22. Poland R. L. The question of routine neonatal circumcision. N Engl J Med. 1990 May 3;322(18):1312–1315. doi: 10.1056/NEJM199005033221811. [DOI] [PubMed] [Google Scholar]
  23. Povenmire R. Do parents have the legal authority to consent to the surgical amputation of normal, healthy tissue from their infant children?: the practice of circumcision in the United States. Am Univ J Gend Soc Policy Law. 1998 1999;7(1):87–123. [PubMed] [Google Scholar]
  24. Price Christopher. Male circumcision: an ethical and legal affront. Bull Med Ethics. 1997 May;NO:13–19. [PubMed] [Google Scholar]
  25. Rickwood A. M. Medical indications for circumcision. BJU Int. 1999 Jan;83 (Suppl 1):45–51. doi: 10.1046/j.1464-410x.1999.0830s1045.x. [DOI] [PubMed] [Google Scholar]
  26. Schoen E. J. Circumcision updated--indicated? Pediatrics. 1993 Dec;92(6):860–861. [PubMed] [Google Scholar]
  27. Shankar K. R., Rickwood A. M. The incidence of phimosis in boys. BJU Int. 1999 Jul;84(1):101–102. doi: 10.1046/j.1464-410x.1999.00147.x. [DOI] [PubMed] [Google Scholar]
  28. Smith A., O'Flanagan D., Igoe D., Cronin J., Forde D., McArdle E., Ko D. Outcome of medical screening of Kosovan refugees in Ireland: 1999. Commun Dis Public Health. 2000 Dec;3(4):291–294. [PubMed] [Google Scholar]
  29. Svoboda J. S., Van Howe R. S., Dwyer J. G. Informed consent for neonatal circumcision: an ethical and legal conundrum. J Contemp Health Law Policy. 2000 Winter;17(1):61–133. [PubMed] [Google Scholar]
  30. Taylor J. R., Lockwood A. P., Taylor A. J. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol. 1996 Feb;77(2):291–295. doi: 10.1046/j.1464-410x.1996.85023.x. [DOI] [PubMed] [Google Scholar]
  31. To T., Agha M., Dick P. T., Feldman W. Cohort study on circumcision of newborn boys and subsequent risk of urinary-tract infection. Lancet. 1998 Dec 5;352(9143):1813–1816. doi: 10.1016/S0140-6736(98)02392-7. [DOI] [PubMed] [Google Scholar]
  32. Van Damme P. Hepatitis B: vaccination programmes in Europe--an update. Vaccine. 2001 Mar 21;19(17-19):2375–2379. doi: 10.1016/s0264-410x(00)00457-6. [DOI] [PubMed] [Google Scholar]
  33. Van Howe R. S. Circumcision and HIV infection: review of the literature and meta-analysis. Int J STD AIDS. 1999 Jan;10(1):8–16. doi: 10.1258/0956462991913015. [DOI] [PubMed] [Google Scholar]
  34. Van Howe R. S. Circumcision and infectious diseases revisited. Pediatr Infect Dis J. 1998 Jan;17(1):1–6. doi: 10.1097/00006454-199801000-00002. [DOI] [PubMed] [Google Scholar]
  35. Van Howe R. S. Does circumcision influence sexually transmitted diseases?: a literature review. BJU Int. 1999 Jan;83 (Suppl 1):52–62. doi: 10.1046/j.1464-410x.1999.0830s1052.x. [DOI] [PubMed] [Google Scholar]
  36. Vogel V. G. Breast cancer prevention: a review of current evidence. CA Cancer J Clin. 2000 May-Jun;50(3):156–170. doi: 10.3322/canjclin.50.3.156. [DOI] [PubMed] [Google Scholar]
  37. WINKELMANN R. K. The cutaneous innervation of human newborn prepuce. J Invest Dermatol. 1956 Jan;26(1):53–67. doi: 10.1038/jid.1956.5. [DOI] [PubMed] [Google Scholar]
  38. Williams N., Kapila L. Complications of circumcision. Br J Surg. 1993 Oct;80(10):1231–1236. doi: 10.1002/bjs.1800801005. [DOI] [PubMed] [Google Scholar]
  39. Wingo P. A., Tong T., Bolden S. Cancer statistics, 1995. CA Cancer J Clin. 1995 Jan-Feb;45(1):8–30. doi: 10.3322/canjclin.45.1.8. [DOI] [PubMed] [Google Scholar]
  40. Wiswell T. E., Smith F. R., Bass J. W. Decreased incidence of urinary tract infections in circumcised male infants. Pediatrics. 1985 May;75(5):901–903. [PubMed] [Google Scholar]

Articles from Journal of Medical Ethics are provided here courtesy of BMJ Publishing Group

RESOURCES