Global Ethics 1 Running head: GLOBAL ETHICS Global Ethics: A Case Study on Female Circumcision Jacqueline M. Ripollone University of Virginia
Global Ethics 2 Introduction It is no question that with many ethical cases, culture can play a huge role. Learning about these differences in cultures has become essential in the education of healthcare providers. We have increasingly seen cases where people refuse medical treatment, whether for themselves or for their children, due to religious or cultural beliefs. When Jehovah s witnesses refuse to receive blood products, even though healthcare providers see it as harmful, we allow their autonomy to over-rule our own feelings on what is best for the patient. However certain traditions do exist that many Westerners view as deplorable and intolerable. One of these is the practice of female circumcision also known as female genital mutilation (FGM) which is the practice of removing parts of a woman s genitals; a painful procedure that could have harmful effects. For years, there have been campaigns around the world to get rid of this practice but many populations, even knowing the risks, still believe in maintaining their traditions. This raises the question: are we just imposing our own Western beliefs on these other cultures? The term female genital mutilation in itself suggests a Western bias, as many of the cultures who practice it do not consider it mutilation. So does any country, especially one such as ours that that stresses religious and cultural tolerance, have the right to force others to change? These issues are seen in this case study. Dr. Jones is participating in a research project on maternal/child health in a rural village where female circumcision is common. While there, she helps treat many women and children suffering from the physical complications of the ritual. Seeing these problems frustrates her although she tries to stay neutral in her feelings on it. A woman from the village, Mosha, who has helped Dr. Jones in the project has become a friend and comes to her with concern. Her daughter is currently of age to have the procedure done and has conflicted feelings. She seeks advice from Dr. Jones on whether or not to have the procedure
Global Ethics 3 done. She knows if the procedure is not done, her daughter may be socially stigmatized and may not be able to marry. The ethical dilemma here is what the actions of Dr. Jones should be. How should she be involved? As a healthcare provider, is it her moral obligation to stop a possibly harmful procedure on a young child or does she have the right to impose her Western beliefs on another culture? Should Dr. Jones stay out of it? To analyze this case, the framework of casuistry will be used. Casuistry Framework According to Beauchamp and Childress (2009), casuistry refers to the use of case comparison and analogy to reach moral conclusions (p. 377). Casuistry takes into account the particulars of a situation and acknowledges the unique details of each case. It also relies more heavily on practical knowledge rather than theory or principles that ask why we make such moral judgments (Beauchamp & Childress, 2009; Toulmin, 1994). Toulmin (1994) argues that it is not the differences in personal morals that contribute to ethical dilemmas, but the unique details of a particular case that often lead to conflicts between values on which we would all agree upon. When these issues confront us, casuists can use simpler examples, and previous cases and experience to help guide them through the unique problems of a more complicated case (Toulmin, 1994). In addition to case comparison, the framework addresses four main concepts which, according to Albert Jonsen (1990), are concepts that are present in any ethical problem no matter the circumstances. These four concepts are medical indications, patient preferences, quality of life, and external socioeconomic factors (Jonsen, 1990). Medical indications include the diagnosis and treatment of the pathophysiological condition of the patient, the goals of available interventions, and benefits and risks of intervening or not intervening. Patient preferences are
Global Ethics 4 based on the patient s own understanding of the risks and benefits and their needs. Not only do the preferences ask What does the patient want? but it also asks Do they fully understand? (Jonsen, 1990). In cases involving children, there should be someone identified who can make decisions for the child (Jonsen, 1990). As far as the component of quality of life goes, this can be subjective and mean different things to different people. The healthcare provider s view of a good quality of life may be different than the patient s (Jonsen, 1990). Finally the external socioeconomic component can include impacts which are psychological, emotional, financial, legal, scientific, educational, religious, etc. (Jonsen, 1990, p 64). Female Circumcision Female circumcision is a practice in some cultures around the globe where a portion of the female genitalia is removed. The World Health Organization (WHO) classifies female circumcision into four major types. Type 1 is clitoridectomy where there is partial or total removal of the clitoris or the skin around the clitoris. Type 2 is excision which is like type 1 but also includes excision of the labia minor and in some cases the labia majora as well (WHO, 2010). Type 3 is infibulation which is partial or total removal of the labia major and stitching of the wound leaving only a small vaginal opening (WHO, 2010; Larsen & Okonafua, 2002). This may be with or without removal of the clitoris (WHO, 2010). Type 4 is any other genital manipulation for non-medical purposes (WHO, 2010). The procedure is performed anywhere from infancy to adulthood and is most common in the western, eastern and north-eastern regions of Africa and in some countries in Asia and the Middle East (WHO, 2010). Reasons for female circumcision vary greatly among different populations. Populations in Somalia and Sudan see it as a way to be more beautiful, clean and feminine. The clitoris is seen as a vestigial male organ and therefore its removal leads to an introduction into
Global Ethics 5 womanhood, marriage and motherhood (Shweder, 2002). Other societies such as some Muslim populations, believe it is required by their religious faith and that it can repress sexual urges (Coleman, 1998; WHO, 2010). Although many Westerners believe it is done to take away a woman s ability to enjoy intercourse, Shweder (2002) cites evidence that woman can still be orgasmic post-circumcision and that it does not dampen enjoyment. Female circumcision is recognized internationally as a violation of women s rights (WHO, 2010) although Shweder (2002) and many women of cultures who carry on the tradition, argue that it empowers women in their society as the ritual allows them to move higher and be accepted into society. Case Analysis Medical Indications To begin to analyze the case, medical indications need to be deliberated. First of all, there are no medical benefits for women from female circumcision (WHO, 2010). There are also serious risks and complications that can result from this practice. Short term complications include hemorrhage, severe pain and blood loss, and shock which could lead to death (Larsen & Okonafua, 2002). The WHO (2010) cites long term issues to be recurrent bladder and urinary tract infections, cysts, infertility and childbirth complications as potential problems. If Type 3 circumcision is done, they will also need to get further surgeries to cut the sealed opening to allow for intercourse and childbirth thus further increasing risks and complications (WHO, 2010). Larsen and Okonafua (2002) also found that circumcised women are more at risk for tear from labor and stillbirth. Infection is also a concern as proper sterilized instruments are not used, although increasingly healthcare providers are performing female circumcisions (WHO, 2010). Shweder (2002) suggests that we should be skeptical of literature of anti-fgm groups because they may be exaggerating the conditions surrounding the practice but he does not deny
Global Ethics 6 complications do exist. When considering the medical indications, it appears that there is no health benefit and in fact only harm, from female circumcision. Knowing this, it appears that Dr. Jones should intervene but there is more to be considered. Patient Preferences Patient preference is the second concept in the casuist framework. In the case here, the patient is only eight years old. In any clinical situation here in the United States, for patients that young the parents are generally the decision makers. In this case the mother, Mosha, is the decision maker and is conflicted about the decision to have her child circumcised. In the ritual of female circumcision, it is generally a requirement. However, the Western belief that the children are forced against their will is a bit skewed according to Shweder (2002). In most of these cultures, there is a celebration surrounding the entrance into womanhood and many of the girls look forward to it; and although it can be painful, the girl views it as a test of courage (Shweder, 2002). Also in the Sudan Demographic and Health Survey of 1989-1990, over 3,000 women were interviewed regarding circumcision. Results showed that 96% of the women who were circumcised said they would have their daughters circumcised (Shweder, 2002). Knowing how heavy the tradition and celebration is surrounding the ritual, it would seem feasible that the child would actually want to go ahead with the procedure. True consent in the United States however also includes knowing the risks, also known as informed consent. The child may be eager to go through with the procedure because she would not yet understand all of the risks and complications from it although that could be said of any young child here that would undergo a procedure in a clinical setting. In this case, because Mosha is working in a setting where she observes the complications of circumcision, she does understand the problems that come with circumcision, hence her conflicted feelings. In a sense, patient preference is at
Global Ethics 7 the heart of the dilemma since Dr. Jones is being asked for advice to persuade the mother towards one direction or another. Should she go along with the preferences of the patient (if the child is eager to be a part of the ritual) and the entire tribe or convince Mosha to change her mind? This part of the analysis does not really make it clear. Quality of Life What does quality of life mean and what does it mean in this context? To just about everybody, having to suffer from disease or health conditions would be a poor quality of life. In that sense, it would seem that knowing the risks and complications stated above, there is a great possibility that she could have a poor quality of life health-wise. A serious infection could not only disrupt her life but lead to death. On the other hand the procedure may not affect her quality of life. Although external socioeconomic factors are a separate concept, it actually is necessary to discuss here. If Mosha s daughter does not get the procedure, she may not be able to get married and may be ostracized from the community. One could argue that this would affect her quality of life as she will not be able to benefit from being a part of the rest of society. So the option of getting circumcised could lead to a poor quality of life if she suffers complications, and the option of not getting circumcised could lead to a poor quality of life as well. External Factors External factors encompass a whole range of factors influencing the issue. One of the most obvious is the pressures of the Mosha s community, and the need to follow cultural traditions to survive in the society. Dr. Jones herself is an external factor who could potentially have a large influence not only on Mosha and her daughter, but on the community itself. So is it right for Dr. Jones to get involved? Is it right for a country to get involved? Well, in some ways
Global Ethics 8 many countries and organizations already have. The WHO and UNICEF have made it their mission to eradicate female circumcision (Shweder, 2002) and many countries have outlawed it. Laws in the United States and France have criminalized it and even some governments in Africa have now banned it as well (Shweder, 2002). Granted these laws only exist within those countries or regions and the question here is whether or not to impose beliefs and laws outside of the country one comes from. One thing Dr. Jones would need to consider is that the World Health Organization has completely denounced it and that this is the organization she is working for. Health professionals in some countries such as Egypt are increasingly becoming involved in performing the circumcisions rather than the members of the community (WHO, 2010). This fact according to the WHO, violates the ethical principle of do no harm. They state that they are particularly concerned over the trend of trained professionals performing female circumcision and ask for it to stop (WHO, 2010). It could then be argued that although Dr. Jones would not be performing the procedure, she would still have the obligation as a healthcare provider to be involved to prevent harm to Mosha s daughter. Case Comparison: The Case of Male Cirumcision In a hospital in Seattle in the mid 1990 s female circumcision was brought to the forefront of healthcare in a United States hospital. Female circumcision was no longer a controversial issue on the other side of the world and our Western culture and views were challenged. In this hospital, Somali immigrants who were giving birth asked if their daughters, as well as their sons, could be circumcised (Coleman, 1998). (It should be noted that in many cultures that circumcise their girls, their boys are also circumcised as well, (Shweder, 2010).) Because there was a small community of these Somali immigrants and refugees in the Seattle
Global Ethics 9 area, they were faced with this dilemma often. They challenged the healthcare providers with a simple question: Why is it ok to circumcise our boys but not our girls? (Coleman, 1998). It is actually a good question. In an article for the American Journal of Bioethics, Michael Benatar and David Benatar (2003) explore the ethics of male circumcision. After reviewing studies to see whether or not there are any actual health benefits to circumcision, they do find some statistics, such as a reduced risk of contracting HIV, that suggest there could be some benefits. They also discover that the belief that it is also more hygienic is not completely true. However they ultimately come to the conclusion that health benefits are still questionable and only slightly outweigh the costs (Benatar & Benatar, 2003). The authors determine that it is neither totally beneficial as a prophylactic measure nor totally harmful (Benatar & Benatar, 2003). Therefore cultural and religious reasons ultimately play a role in the decision of families to circumcise their sons. They point out that culture and religion were the reasons that male circumcision was performed in the first place, and that we have accepted it as it has become ingrained in our culture, whether or not there are actual benefits. Culture is also the main reason for female circumcision and therefore we should not be too quick to judge it (Benatar & Benatar, 2003). Although female circumcision can be more harmful than male circumcision (and therein lies the difference), the authors suggest that people need to step back from their cultural unfamiliarity when discussing female circumcision (Benatar & Benatar, 2003, p. 44). The people in this Seattle hospital were also not quick to dismiss the cultural importance of circumcision for the female infants (Coleman, 1998). These healthcare providers told that if it was not done at the hospital, they would get a traditional one done elsewhere. It would either be performed by someone in the community, or they would fly their babies out to their original
Global Ethics 10 country to get it done there. Recognizing that the hospital would be a less risky route, a compromise was proposed. The hospital agreed that they would perform a symbolic cut. Nothing would be removed and there would be no scarring (Coleman, 1998). Although this compromise satisfied many of the Somali women, the procedures would never be carried out since anti-fgm groups in the community ultimately won out. The authors of this article note the extraordinary sensitivity of the workers in this hospital and express their disappointment in the fact that the compromise ultimately failed due to continued outrage over female circumcision (Coleman, 1998). Conclusion After the analysis it appears that circumcision could possibly lead to medical complications and a poor quality of life. However it could also lead to acceptance and marital success in the society and it may not even be against the daughter s wishes if she is eager to be a part of the ritual. There are two paths that Dr. Jones could take. One is that she could just not get involved and ultimately leave the decision to Mosha. Assuming that Mosha would go ahead with the circumcision, the pro of this decision would be that the daughter would be accepted into the community and there would be no conflict between Dr. Jones and the village. The con of the decision would be the complications that Mosha s daughter could suffer. If she suffered complications such as shock and infection, it could even lead to her death. Mosha or the World Health Organization could hold Dr. Jones responsible for not intervening. The other decision is to intervene and prevent the circumcision. The obvious pro here is that the young girl would not undergo a painful procedure and not have health issues as a result. Also, perhaps Mosha is a respected person of the community, and after seeing such a person denying her daughter a circumcision, the others in the village may begin to agree that the
Global Ethics 11 practice is harmful. The con here is that she would not be accepted into the community but it could go even beyond that. The village that she is working for may become offended and angry at Dr. Jones for imposing her Western beliefs on the people of the village. They may ask her group to leave which could ultimately be a loss for the village since Dr. Jones and her group are offering free medical aid and helping members of the community. In general, a country intervening to eradicate female circumcision could ultimately lead to failure if they are not careful. Shweder cites instances where attempts to eradicate the practice in some villages were insensitive approaches and therefore unsuccessful. As part of the WHO s declaration to end the practice, they discuss the need to ensure the participation of the men and leaders in the village to help eliminate the practice (WHO, 2010). A leader in the Somali group in Seattle also stressed the need to work with the other members in the community and the mothers to change a harmful practice (Coleman, 1998). In other words it is clear that if the US does want to eradicate female circumcision, it would be important to work with the community leaders and the females and mothers in the community rather than simply telling them that it is harmful and morally wrong so therefore it shouldn t be done. Working alongside the community and fully respecting understanding their practices, culture and traditions, will always be necessary when dealing with female circumcision. Because Dr. Jones is working within the community and has tried her best to not let her own culture blind her, she is already further along than many others who want to eradicate it.
Global Ethics 12 References Beauchamp, T.L., & Childress, J.F. (2009). Principles of Biomedical Ethics. 6th Edition. New York: Oxford University Press. Benatar, M. & Benatar, D. (2003). Between prophylaxis and child abuse: The ethics of neonatal male circumcision. The American Journal of Bioethics, 3, 35-48. Retrieved October 16, 2010, from http://dx.doi.org/10.1162/152651603766436216 Coleman, D. L. (1998). The Seattle compromise: Multicultural sensitivity and Americanization. Duke Law Review, 47, 717-783. Jonsen, A.R. (1990). Case analysis in clinical ethics. The Journal of Clinical Ethics,1, 63-65. Larsen, U. & Okonafua, F.E. (2002). Female circumcision and obstetric complications. International Journal of Gynecology and Obstetrics,77, 255-265. Retrieved October 16, 2010, from http://www.sciencedirect.com doi:10.1016/s0020-7292(02)00028-0 Shweder, R.A. (2002). What about female genital mutilation? and why understanding culture matters in the first place. In R. Schweder, M. Minow, & H. Markus (Eds.), The multicultural challenge in liberal democracies (pp. 216-251). New York: Russel Sage Foundation Press. Toulmin, S. (1994). Casuistry and clinical ethics. In E.R. Dubose, R.P. Hamel, & L.J. O Connell (Eds.), A matter of principles? Ferment in US bioethics (pp. 310-318). Valley Forge, PA: Trinity Press, International. World Health Organization. (2010). Female genital mutilation. Retrieved October 3, 2010, from http://www.who.int/mediacentre/factsheets/fs241/en/index.html