Ethics

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Providing non-therapeutic male circumcision

 

 

I am performing NTMC (non-therapeutic male circumcision) in a religious capacity, not in my role as a doctor. Do I still need to adhere to the same professional standards?

Yes, the GMC makes clear that if a doctor agrees to perform any procedure for religious or cultural reasons, they must meet the same standards of practice required for performing therapeutic procedures, including:

  • having the necessary skills and experience to perform the procedure and use appropriate measures, including anaesthesia, to minimise pain and discomfort both during and after the procedure;
  • keeping their knowledge and skills up to date;
  • ensuring conditions are hygienic; and
  • providing appropriate aftercare.

In addition, in England, the carrying out of NTMC by medical providers is a ‘regulated activity’ for the purposes of the Health and Social Care Act 2008. It is an offence to provide regulated activities in England without registering with the CQC. The CQC Registration under the Health and Social Care Act 2008: scope of registration states: 

CQC - The scope of registration

‘Surgical procedures carried out for religious reasons, such as circumcision, are included where they are carried out by a health care professional. Where a health care professional carries out surgery for religious purposes they will be acting in their capacity as a health care professional rather than in a religious or spiritual role. This is because a registered health care professional's code of practice will prohibit them from disregarding the need to have appropriate skills, experience, equipment and facilities for this procedure and they cannot 'opt out' of their core duties and responsibilities as a registered health care professional, even if they are acting in a spiritual or religious role.’

                                               CQC, Registration under the Health and Social Care Act 2008: scope of registration

Doctors are also expected to be registered in Wales with Healthcare Inspectorate Wales (HIW) and in Scotland with Healthcare Improvement Scotland (HIS). 

 

What if circumcision is outwith my usual clinical area?

Doctors unfamiliar with circumcision who are asked about it, should seek advice about the physical risks from doctors experienced in conducting circumcisions, or a urologist or paediatric surgeon. Religious and cultural organisations may be able to give advice and suggest practitioners who perform circumcisions. It may be necessary to refer a family to a paediatric surgeon, urologist or other doctor experienced in performing the operation for advice and care.  

 

Are there any specific standards that I should be aware of?

In addition to standards set by organisations which set clinical guidelines (see resources below), there are standards to which some practitioners subscribe, set by external collectives, associations and societies. 

The GMC also notes in its guidance on personal beliefs:

GMC guidance - inviting a religious adviser

'23. If you are carrying out circumcision, or another procedure, for religious reasons, you should explain to the patient (or, in the case of children, their parents) that they may invite their religious adviser to be present during the procedure to give advice on how it should be performed to meet the requirements of their faith.'

GMC, Personal beliefs and medical practice

 

Fitness to practise cases

In 2015, a doctor was erased from the medical register for serious and wide-ranging failings in his clinical practice and repeated instances of dishonesty. Parents of a child he had circumcised claimed that the child was left traumatised and suffered an infection as he did not take hygienic precautions. The circumcision took place at the child’s home.

The doctor was reported not to have the relevant indemnity insurance for his private work or the necessary registration with the CQC.

GMC reference 5206776

In 2016, a doctor was suspended from the medical register following concerns about his conduct during the circumcision of a four/five-week-old child; placing the patient at unwarranted risk by failing to:

  • obtain informed consent;
  • make adequate enquiry into a child’s medical history;
  • carry out a surgical procedure in adequate premises; and
  • maintain clean and/or sterile instruments

Leicester Magistrates Court also fined the doctor £2,700 and ordered him to pay over £30,000 court costs after he admitted performing circumcisions without being registered with the Care Quality Commission (CQC).

GMC reference 3644948

 

Can patients obtain NTMC on the NHS?

Although non-therapeutic circumcision is not a service which is generally provided free of charge, some doctors and hospitals have been willing to provide circumcision without charge, rather than letting the procedure be carried out outside a health setting and/or without medical oversight. In such cases, doctors must still be able to justify any decision to circumcise a child based on a best interests assessment.

In Scotland, the government has produced guidance which advises that midwives should ask all parents at ante-natal booking if their religion would require their child to be circumcised; and that circumcisions should be undertaken in specialist centres at the children's centres in Aberdeen, Tayside, Glasgow and Edinburgh.

 

Checklist for doctors providing NTMC

  • adherence to professional standards expected of doctors, even if acting in a different capacity e.g. necessary skills and experience;
  • considered decision-making process e.g. consent, best interests assessments;
  • appropriate documentation e.g. accurate and legible records, written consent;
  • appropriate equipment and clinical standards e.g. suitable premises. If general anaesthesia is used, full resuscitation facilities must be available;
  • where necessary registration with a regulator e.g. in England with the CQC, in Wales with HIW, and in Scotland with HIS; and
  • adequate indemnity insurance.

Next page - Record-keeping

 

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