Female_Genital_Mutilation

Female Genital Mutilation/Cutting Patricia Tener ITT Technical Institute GE265, Ethics in Society – Test Out Female Genital Mutilation - 25 November 2011 ABSTRACT Genital mutilation, particularly female, is thought to be an atrocity against young children and adult women. What are the ethical theories that abound in relation to the circumstance of female circumcision' What is the background of Female Genital Mutilation/Cutting (FGM/C)' In order for an ethical theory to be useful, the theory must be directed towards a common set of goals. Ethical principles are the common goals that each theory tries to achieve in order to be successful. These goals include beneficence, least harm, non-maleficience, respect for autonomy and justice. There are several ethical theories that can be applied to FGM/C; however, none are without fault. The theories do bring significant characteristics to the decision-making process, however, how does one decide which ethical theory is the correct one to utilize in any given situation. The best way to do this is to combine a variety of theories in order to get the most ethically correct answer. FGM/C is unethical in any sense and none of the ethical theories presented here make it ethical in any sense of the word. Female circumcision has been defined by the World Health Organization (WHO) as follows: Female Genital Mutilation comprises all procedures that involve partial or total removal of female external genitalia and/or injury to the female genital organs for cultural or any other non-therapeutic reason. (Female Genital Mutilation, 1996) This description or more specifically use of the word “mutilation” in itself has caused problems because this description may be ethically inappropriate. Descriptively, the word “mutilation” may be exaggerated, because it fails to distinguish between the four types of genital cutting recognized by the WHO. Evaluatively, the name is not a neutral description but a severely hostile judgement, since it condemns those who seek, authorize and perform such cutting as mutilators of human beings. Culturally, the name is disrespectful, because it fails to respect the motivation with which those who request the procedure for their daughters are acting. Personally, the name is again disrespectful, because it tells women who were subjected to procedures, that they have been mutilated, by their parents or other family members. (Cook, 2008) Female circumcision is currently practiced in at least 28 countries stretching across the center of Africa north of the equator; it is not found in southern Africa or in the Arabic-speaking nations of North Africa, with the exception of Egypt and is defined as the partial or complete removal of the clitoris, prepuce, or labia or a girl or young woman. It occurs among Muslims, Christians, animists and one Jewish sect, although no religion requires it, generally as one element of a rite of passage preparing young girls for womanhood and marriage. It is an integral part of the societies that practice it, where patriarchal authority and control of female sexuality and fertility are givens. In communities where a person's place in society is determined by lineage traced through fathers, it reduces the uncertainty surrounding paternity by discouraging or preventing women's sexual activity outside of marriage. Although the societies that practice circumcision vary in many ways, most girls receive little education and are valued primarily for their future role as sources of labor and producers of children. In some communities, the prospective husband's family pays a bride price to the family of the bride, giving his family the right to her labor and her children; she herself has no right to or control over either. (Althaus, 1997) A girl's virginity may be considered essential to her family's ability to arrange her marriage and receive a bride price, as well as family honor. In Somalia, for example, a prospective husband's family may have the right to inspect the bride's body prior to marriage, and mothers regularly check their infibulated daughters to ensure that they are still “closed.” In this context, parents see both FGM/C and early marriage as means of ensuring that their daughter remains "pure" and thus worthy of the bride price. (Althaus, 1997) In many cultures, considerable social pressure is brought to bear on families who resist conforming to this tradition. In some places, a girl who has not been circumcised is not considered marriageable. Among the Samburu of Kenya, who consider uncircumcised girls unclean, promiscuous and immature, girls are generally circumcised at age 14 or 15, usually just before they are married. A girl with a younger brother may undergo circumcision if she remains unmarried by her late teens, since custom dictates that a boy with an uncircumcised older sister may not be initiated into the warrior class. (Althaus, 1997) Girls' desires to conform to peer norms may make them eager to undergo circumcision, since those who remain uncut may be teased and looked down on. In addition, the ritual cutting is often embedded in ceremonies in which the girls are feted and showered with presents and their families are honored. A girl's wishes, in any case, are often irrelevant; it is her family--often the father or elder female relatives--who decide whether she will undergo circumcision. According to one Yacouba father, “My daughter has no choice. I decide. Her viewpoint is not important.” Indeed, girls have very little choice. Given their age and their lack of education and resources, they are dependent on their parents, and later on their husband, for the basic necessities of life. If they remain uncircumcised and their families are therefore unable to arrange a marriage, they may be cast out without any means of subsistence. (Althaus, 1997) Because of their lack of choice and the powerful influence of tradition, many girls accept circumcision as a necessary, and even natural, part of life, and adopt the rationales given for its existence. A variety of justifications are given by respondents who favor continuation of the practice, including preservation of virginity before marriage, fidelity after marriage, enhancement of the husband’s sexual pleasure, enhancement of fertility, prevention of infant and child mortality, cleanliness and religious requirements, but tradition is by far the most commonly mentioned reason. (Althaus, 1997) In the abovementioned instances, Rights ethical theory has taken place. The culture has taken the forefront, regardless of laws that are in place that prohibit FGM/C. The parents do not care that there are laws against it, they feel that it is an important part of their society and as such, they have the right to make the decision for this procedure because it is part of their culture and no one should interfere. Like all professions, medicine has its own ethical code and principles of conduct. One rule of conduct is "First, do no harm." Removing a normal, healthy body part and causing unnecessary pain is doing harm. Some doctors who circumcise acknowledge the associated pain and then dismiss it by saying, "It only lasts for a minute," implying that it is acceptable to subject an infant to unnecessary pain as long as it is temporary. Even if the pain is temporary, this careless attitude about inflicting pain violates the ethical principles of the medical profession. It also violates general moral principles to subject anyone, particularly a defenseless infant or young child, to any unnecessary pain for any period of time. As reported in the New England Journal of Medicine, "Failure to provide adequate control of pain amounts to substandard and unethical medical practice." Based on these standards and given that there is no effective and safe anesthetic that will eliminate circumcision pain, all circumcisions would be prohibited. (“Circumcision, ethics and medicine”) According to the Hippocratic oath, another important principle of medical practice is that the patient’s welfare shall be the doctor’s first consideration. In the case of circumcision, doctors generally tend to ignore this rule, while parents falsely believe they are following it. One physician defended circumcision by saying that "within the community at large, at the present time, there is not a tremendous amount of support for saying to parents you shouldn’t do this." For this physician, community attitude seems to supersede the patient’s welfare. Isn’t it the medical profession’s responsibility to lead rather than follow regarding community health care standards' (“Circumcision, ethics and medicine”) Currently, it has been observed that an estimated 130 million girls and women have undergone the procedure, in some form, and that at least 2 million girls a year are at risk of undergoing some form of this procedure. Further, under the impact of immigration, the practice is now found in regions where it has not been prevalent in the past (African immigrant communities in Europe, Canada, Australia and the United States). (“Changing a harmful,” 2008) Ethical concerns are raised not simply from the inherent bodily insult of FGM/C, but from its known consequences. Choice of ethical response among physicians brings out the ambivalence of the historical medical ethic, Do No Harm. In the language of modern bioethics, this is embodied in the principal of non-maleficience. FGM/C is no doubt safer in medical than in unskilled hands, so that, for instance, excessive bleeding can be better contained, but at best the procedure bears an irreducible minimum risk of injury, and in almost all cases is demonstrably non-therapeutic. A direct application of the Do No Harm principle therefore indicates that physicians should not undertake FGM/C. (Cook, 2008) Another aspect of non-maleficience is to minimize harm. The case for medical involvement in these cases is that when parents feel compelled to have FGM/C for their daughters, and unskilled practitioners, such as family members are available to undertake procedures in non-sterile conditions and by crude means, harm will be minimized if physicians agree to conduct procedures and can do so by minimally invasive means. A key role of physicians requested to undertake FGM/C is to explain why they cannot, and to educate requesting parents and others about risks of procedures in unskilled hands, and the violation of women’s bodily integrity due to these practices. Physician responses should give less emphasis to punitive aspects of FGM/C, however, than to aiding parents, families and communities to understand the protective purpose the medical profession advances in eliminating such procedures. Health care providers are urged to collaborate with national authorities, non-governmental organizations and, in some cases, religious leaders, to support measures aimed at elimination of this harmful traditional practice. (Cook, 2008) These are examples of Rule Utilitarian and Act Utilitarian ethical theories. Removal of a body part without any medical reason is not ethical, and the laws state this as fact, however, it is safer to have a medical professional perform the procedure as stated below, but this gives rise to flaws in these ethical theories because of the pain inflicted, the fact that the patient has not given their “Informed Consent”, and that there is no medical reason for removing the part. Justice, non-maleficience, respect for autonomy are all violated when these theories are utilized. The main ethical drawback of FGM/C is that; it is a senseless practice which provides no direct benefit to girls on whom it is performed; it inflicts undue harm on young girls (primary victims); and it is performed without consent, these are all violations of essential medical ethics. Undefined medical indications for FGM/C and possible risks to females make it ethically unacceptable. (Elsayed, Elamin & Sulaiman, 2011) The justification for FGM/C appears to be grounded in the social desire in terminating or reducing feelings of sexual desire in women so that they will be much less likely to engage in pre-marital sexual relationship or adultery. Nevertheless, it is not considered a major social and health problem in the countries where it is practiced. (Elsayed, Elamin & Sulaiman, 2011) Medical Ethics is at the heart of the FGM/C issue primarily because it is considered as a medical/surgical intervention performed by some doctors and other medical workers (e.g., midwives). Usually, physicians or other medical professionals are asked to perform FGM/C which has no recognized medical value; but on the contrary, it harms the victims. A very valuable question comes forward “Should the medical professional refuse to perform FGM/C'” There is no easy answer to this question. FGM/C is a social question that is practiced. Medical professionals are often confronted with ethical dilemmas when they are asked to perform it. The society accepts it and people expect them to do it better than the non-medical or less trained health workers, who performed it in the past. But the more recent rules and regulations of the profession inhibit them from doing it. “Ethics also refer to the moral reasoning which underlie human relationships and the ways in which they treat each other.” The ethical dilemma with performing FGM/C comes from the deeply held social and religious beliefs about the practice and the moral beliefs that are used by the people who support and continue the practice. In this case if the medical professional performs FGM/C, he/she does not need any reasoning for his/her action. On the other hand, refusal may be considered as a resistance or violation to social norms (morality) which is a very serious insult to cultural identity. Violating social tradition (morals) is considered as disrespect to them. The medical professional may lose their credibility and respect as a community oriented health worker. Alternatively, performing medically meaningless and harmful procedures by medical professionals is not only unethical; but it is equally illegal. FGM/C is considered as a surgical procedure that requires notable medical skills and expertise. So it is an obvious violation of the principle of non-maleficience. (Elsayed, Elamin & Sulaiman, 2011) The logical and ethical answer to this is yes – the medical professional – has to refuse performing such harmful and unneeded procedures, because violating social norms for the sake of society members is more valuable and morally and ethically acceptable. This is a basic, universal and fundamental ethical principal that applies to all people. (Elsayed, Elamin & Sulaiman, 2011) FGM/C is considered a surgical intervention which requires obtaining informed consent from the person on whom the surgery is being performed. This should be done without any question or counter arguments. It is justified in the ethical principles of autonomy, to ensure justice and to minimize risk. Informed consent is usually obtained from a competent person (adult with a sound mind), or from the parents or legal guardians, in the case of children. This is the practice in regard to daily scheduled health care. The only exception is in emergency situations where urgent interventions are sought. FGM/C is neither a medical emergency, nor is it medically necessary. Rather it is sought out for children by a proxy (mother or family member) and is not in the best interest of the child. If this procedure is delayed until the child reaches the age of consent (generally 18), they will be able to make an autonomous decision that pertains to their own well being. (Elsayed, Elamin & Sulaiman, 2011) FGM/C obviously violates the fundamental ethical principles of bodily integrity, autonomy and self determination without the full informed consent of the victim. Therefore, it violates the same social norms and social integrity. Except for the unquestionably curative therapeutic reasons, any procedure made on the body is considered unethical. The drastic nature of FGM/C; its irreversibility and lack of urgency without consent, or at least by parent consent make it an even more illegal action and shows the flaws in utilizing ethical theories to come to a conclusion. The obvious solution to the problem of FGM/C is to understand the cultures in which it is performed, refuse to perform it in line with Rule Utilitarianism, focus on education of the populations, and utilize the ethical principle of non-maleficience in relation to those cases where the respect for autonomy prevails and the individual signs an informed consent. REFERENCES Althaus, F. (1997). Female circumcision: Rite of passage or violation of rights', International Family Planning Perspectives, 23(3), Retrieved from http://www.guttmacher.org/pubs/journals/2313097.html Circumcision, ethics and medicine. (n.d.). Retrieved from http://www.circumcision.org/ethics.htm Cook, R. (2008). Ethical concerns in female genital cutting. African Journal of Reproductive Health, 12(1), Retrieved from http://www.bioline.org.br/pdf'rh08001 Elsayed, D., Elamin, R., & Sulaiman, S. (2011). Female genital mutilation and ethical issues. Sudanese Journal of Public Health, 6(2), Retrieved from http://www.sjph.net.sd/files/Vol6N2/Brief Communications1.pdf Female Genital Mutilation: Report of a WHO Technical Working Group, Geneva, July 1995. (World Health Organization: Geneva, 1996) (2008). Changing a harmful social convention: Female genital mutilation/cutting. Retrieved from ABC Typografia website: http://www.unicef-irc.org/publications/pdf/fgm_eng.pdf