This issue Director of Health and Disability Proceedings Aaron Martin highlights a case that doctors may be interested in. While it was a case that did not go to a disciplinary hearing, it raises some thought-provoking questions about circumcision procedures on young boys.
The Health and Disability Commissioner (HDC) is responsible for upholding the Code of Health and Disability Services Consumers' Rights and redressing breaches of it. As HDC's Director of Proceedings, my role is to decide whether proceedings should be brought in cases referred to me by the Commissioner. Doctors play key roles in this consumer protection work, whether as expert clinical advisors to the Commissioner, as expert witnesses in the small proportion of complaints that result in an HDC proceeding, or as members of the tribunal that hears disciplinary charges.
It is no surprise to find doctors actively lending their time and expertise to ensuring trust in the practice of medicine is not undermined by the actions of a few. A case from 2009 where I decided not to take a disciplinary proceeding against a medical practitioner highlights an issue that may be of interest to doctors.
General or local anaesthesia for circumcision of young boy?
Mr and Mrs B decided to have their four- year-old son, Master B, circumcised for religious reasons. On 23 January 2009 Dr C, a General Practitioner performed the procedure at a medical centre. A local anaesthetic was administered. However, Master B was distressed throughout the procedure and would not lie still. Attempts were made to hold Master B still, but these were unsuccessful and Dr C was unable to stem the bleeding from the frenular artery. Master B was transferred by ambulance to hospital, where the bleeding was deemed too profuse to be stopped with local pressure alone. He subsequently underwent haemostasis and a revision of the circumcision under general anaesthetic, and was discharged on the morning of 24 January 2009 (Case 09HDC00810).
As the Commissioner's report makes clear, whether the procedure was unreasonable depends not only on 'accepted practice' but also on the surrounding circumstances. Here, Dr C failed to follow his own selection criteria when assessing whether Master B was a suitable candidate for circumcision (which resulted in an inappropriate selection), and did not ensure he had adequate support should complications arise during the procedure. The Commissioner concluded that Dr C failed to provide services of an appropriate standard. He was unable to obtain a penile block; his method for determining whether the anaesthetic had worked was inadequate; he failed to consult Mr and Mrs B and reassess the situation once it became clear that Master B was in pain, distressed and was not going to cooperate; he used unreasonable force to restrain Master B during the procedure; and he used inappropriate sutures in his attempts to stem the bleeding.
The Royal Australasian College of Physicians' (RACP) 2004 'Policy Statement on Circumcision' indicated that circumcision on a child of the age of Master B is usually carried out under a general anaesthetic and regional block. This statement represented a policy agreed by a number of other associations including the Australasian Association of Paediatric Surgeons, the New Zealand Society of Paediatric Surgeons, the Paediatric Society of New Zealand, and the Royal Australasian College of Surgeons.
In these circumstances the Commissioner found that Dr C had a duty to inform Mr and Mrs B of the increased risk of complications and what those complications were, and bring to their attention the recommendation that the procedure be carried out under general anaesthetic. Dr C accepted that he failed to do so.
The Commissioner referred Dr C to me, as Director of Proceedings, to consider whether to institute proceedings.
While the child's best interests should be paramount - and the case of Master B concerned a four year old who experienced obvious pain and distress - in other cases there may be tensions for parents and GPs in deciding how the child's best interests are to be met. If, for example, there is a social, cultural and religious demand for male circumcisions and GPs do not perform the procedure, this may result in parents seeking more risky non-medical options. Socio-economic factors may also have a bearing on arguments in support of local anaesthesia.
Reviewing and setting appropriate standards for GPs performing circumcisions is likely to be best achieved by drawing on views from the medical profession, public health experts, and those who may seek the procedure for their children, including in New Zealand the Polynesian, Islamic, and Jewish communities.
In the case concerning Dr C, I decided clarity about such issues was unlikely to be helpfully advanced by an adversarial hearing at this time. Although the Code was clearly breached by Dr C, in my view this was not (by a narrow margin) a case where the public interest required a disciplinary proceeding.
Since the case concerning Dr C, RACP has published a statement on circumcision of infant boys for doctors and to assist parents who are considering having this procedure undertaken on their male children (September 2010). Noting recent renewed debate about the potential health benefits and the ethical and human rights issues around infant male circumcision, the statement says "it is reasonable for parents to weigh the benefits and risks of circumcision and to make the decision whether or not to circumcise their sons".
It goes on to say that when "the operation is to be performed it should be undertaken in a safe, child-friendly environment by an appropriately trained competent practitioner, capable of dealing with the complications, and using appropriate analgesia".
Is there adequate guidance available to GPs performing circumcisions on young boys (as opposed to infants) about the appropriateness of local anaesthetic in those circumstances?
Questions around the standards that apply to GPs performing circumcisions will, I suggest, be of interest to other doctors as well. So, I end where I began, recognising the huge contribution doctors can make to protecting public safety by engaging with questions about the professional standards that apply to their practice. Those interested in a more in depth discussion of the issues will find the RACP policy statement on circumcision of infant males at http://www.racp.edu.au/page/policy-and-advocacy/paediatrics-and-child-health.
Director of Proceedings
NZ Doctor, 20 April 2011