Bioethics Discussion Blog: July 2006

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Monday, July 31, 2006

Medical Decisions: Role of the Physician's Personal Opinion

These days, medical paternalism has seemingly faded and has been replaced by the concept of patient autonomy. Current view of medical practice warns against physicians "deciding" for the patient. There has even been emphasis that the decisions should be 100 percent by the patient with no personal suggestions by the physician. I brought this issue up on my currently inactive "Bioethics Discussion Pages". I thought the responses were quite interesting, so I am copying the topic and comments here. The oldest comments are at the bottom of the page. Perhaps my current visitors have some thoughts on the subject or what they have experienced. If so, feel free to write your comments to my blog. ..Maurice.





Every person makes decisions based on their own experience, value system, goals and morals. In medical decision making, a patient draws on these and also, hopefully, an analysis of the burdens and benefits of the anticipated test or treatment. The objective facts should be provided by their doctor. Doctors also will have their own personal opinions as to what medical decisions would be appropriate for themselves but should they express their opinions of what would be appropriate for the patient? If a patient asks the doctor "What would you do if you were me?" How should the doctor answer? Should the doctor ever give a personal opinion without being asked?

Here is the question:

Should doctors tell patients their own personal opinions of what should be done?

---- THE DISCUSSIONS ----

Date: Sat, Apr 22, 2000 5:34 AM From: davidh@midusa.net To: DoktorMo@aol.com

DoktorMo, I am a nurse of 22 years experience. I think that patient families are often "getting a crash course in bioethics" at the bedside of their family members. Thus they are often not in the mind to do a lot of learning and they often don't have time to do the learning because a decision must be made (to do the surgery, to do the trache, to do the g-tube, to place on the vent).

In a perfect world, families would have thoughtful and deep discussions about what they would do in the event of handicap, disability, choices about technology. You know, the kind of discussions that we health professionals OFTEN have with our family members. So families may not have the time to make the decision and due to their "limited" life experiences they have no idea of what can be the long term out come of their decisions that day. Of course, we as health care professionals don't either, but we have pictures of the worst case and best case scenarios in our minds and families generally don't have that.

I was priveleged to hear a health ethicist speak last summer and his feeling was that as health providers we were often "under involved" in helping our clients with decision making. He was not advocating patriarchy--in fact he categorically deplored it. But the opposite of patriarchy is this atmosphere of "consumerism" where the family decides, as if they were fully informed and insightful consumers. We as health care providers must realize that we bring to the table some specific knowledge about the range of possible outcomes and how long terms disability affects families in a financial and dynamic way. Let's face it, people: sometimes what we send people home to live with devastates the entire family.

As a group both doctors, nurses and families get caught into a swirl of, "Because we can provide it, we ought to." Please do not think that I am advocating the opposite. I am not. GIven the widest range of choices, I am pretty convinced that some families will choose to proceed with aggressive, life sustaining care in the face of profound disability. But somehow, families must be exposed to the glimpse of profound affect that this will have on them personally, financially and within their family dynamic and they must understand that they never loose their opportunity to re-choose and become less aggressive in their curative approach while always maintaining an emphasis on CARE.

Good discussion forum.

Janet, RN, KS


Date: Fri, Mar 24, 2000 6:49 AM From: "ocsio"@hotmail.com;ann@marist.edu.ph;;; To: DoktorMo@aol.com

Doctors should always give patients adequate facts and figures. Personal opinions if solicited should be given, but never volunteered. I tell my patients to go home to talk it over with relatives and friends. I encourage my patients to see other medical experts for second or more opinions. Patients should feel that they have exhausted all possible sources of objective as well as subjective matters regarding their cases, prior to coming back to me for definitive but within sound medical/ surgical decision.

Marianne A. Ocsio, Obsetrician-Gynecologist


Date: Sat, Jul 26, 1997 2:11PM From: DocReading@sprintmail.com (William H. Reading, MD) To: DoktorMo@aol.com

I offer personal opinions to my patients. I make sure that patients are aware that I am making a personal opinion. I am also sure that patients are aware of both risks and benefits. In most matters of deciding in major situations, people ask, "if you were in my situation, what would you do?" I ask this of others in medical settings as well as in other situations involving a judgement call. I have asked this question of my peers in deciding the best approach to treating a difficult patient. Patients can often be swayed one way or another by this personal information but it does not mean that they should be deprived of having it. In an involuntary medication hearing, I have been asked by a Judge, "Would you recommend this treatment for one of your own family members?" I believe that this information is a powerful attestation in helping to decide a difficult issue.


Date: Mon, Jul 14, 1997 7:57 PM From: Nrse4morph@aol.com To: DoktorMo@aol.com

Yes, if asked they should be allowed to do so with care. They should not be compelled to do so, If they are aware that the patient is seeking to lay resonsibilty onto someone other than themselves it is not appropriate.

Doctors wield a great deal of power even today. They are sometimes the only source of real infromation based in reality that a patient receives in an out of the hospital setting.

In hospital there are numerous sources of information available to the patient, but either the patient may not avail themselves of those resources or those resources may not inform the patient out of fear of an aggressively controlling physician.

Another factor that must be considered when an opinion is given by a physician is that there is at least the potential for a conflict of interest. In fee for service to run up the bill. In managed care to keep costs low.

Doctors must be careful and use many of the same techniques that other healthcare personnel utilize to avoid the pitfalls of even seeming to impose their own value systems onto the patient. Even if the patient seems to want just that at the time they are very likely to be resentful later


Date: Sun, Jul 6, 1997 3:45 AM From: shaolin@henge.com@henge1.henge.com (Robert Wesley) To: DoktorMo@aol.com

The proper answer to this question is, yes and no, or, more precisely, sometimes yes and sometimes no. The real question is, Under what circumstances would it be appropriate?, and the answer to that question involves judgment, a quality which we do not seem to value much anymore, and the specific relationship between the doctor and the patient. Take the question of whether one should undergo chemotherapy for cancer and add whatever details you like about 5-year survival rates, etc., and then ask this question in each of the following circumstances: 1. A doctor and patient who have known each other for 40 years and who are good friends outside of their professional relationship. 2. A doctor in a clinic who is seeing the patient for the first time and who will likely not ever see the patient again. 3. A doctor who knows the patient well enough to know that the patient is easily swayed by anyone else's opinion and particularly by opinions expressed by authorities. 4. A doctor who knows the patient well enough to know that the patient is independent and that the patient will take the doctor's opinion as merely one more piece of information in making his own decision. Etc., etc., etc. In my opinion, these differences are the essence of the matter, and the best doctors are those who possess the judgment to discern the differences.

Robert Wesley


Date: Thu, May 22, 1997 7:31 AM From: 106721.2574@compuserve.com (Dorothy Onunwakolam) To: DoktorMo@aol.com

Q : Should a doctor ever give a patient his personal opion even when requested by patient ?

My A : Yes, if patient is well known to me and trusts my judgement , I will give him my honest opinion but make it clear that he does not have to take it


Date: Thu, May 8, 1997 7:08 AM From: JMG.Keijman@STUDENT.UNIMAAS.NL (JMG Keijman) To: DoktorMo@aol.com

Being a medical student who has recently made the step from theory to practice I have been thinking about this a lot. This is how I think about it (any comments are very much appreciated): There should be a distinction between the patient asking for the doctors opinion or not. If the patient does not ask for the doctors opinion, he should not give it. Some people do not appreciate it. In this case the doctor should limit himself to thoroughly explaining all possibilities and consequences of what can be done. The patient should be given the oppertunity to think about it, discuss it with family and friends and ask for more information or a second opinion. In most cases the choice will be easy, because the consequences are very clear and distinct. If the patient does ask for the doctors personal opinion, it will mostly be in the cases in which the consequences are unclear and undistict. The doctor should give his personal opinion in these cases. However, some things should be remembered: 1. Stress that it would be YOUR decision if you were in their shoes 2. explain WHY you would make that decision 3. Emphasize that there are OTHER OPTIONS that the patient should consider.

Jeroen Keijman, dutch medical student


Date: Thu, Apr 10, 1997 4:51 PM From: SANGRIA111@aol.com To: DoktorMo@aol.com

My view on whether doctors should give their personal opinion to a patient leans both ways. If the patient asks for the doctors opinion, the doctor has a right to express his views. however, if the doctor is not asked about his opinion, he or she should not give it just for the simple fact that they were not asked. We look up to and respect doctors views and sometimes even treat them like God, but there are just some decisions that should be handled by the patient and their families and not the physician.

Mark A. Walker, Univ. of Oklahoma College of Nursing


Date: Wed, Feb 19, 1997 6:25 AM From: theguild@teleport.com To: DoktorMo@aol.com

Two years ago I wouldn't have had more than a mild opinion of my own to your question. After brain surgery to remove a large, but benign tumor, which has left me in a very precarious state, I have a definite answer - YES. Medical doctors try so hard to detach themselves from the psychological and emotional aspects of the disease, that they often appear as clinical automatons, bearing diagnoses, treatment and prognoses in logical, digitized, even-breathed tones, leaving the patient's psyche and soul as disconnected from the physician as he can get. A personal opinion reconnects patient and doctor and puts them back into the realm of person to person. In today's medical world, it has become increasingly necessary to be your own informed advocate - much as the prisoner on death row familiarizes himself with all facets of the law to enable a pardon, a patient had better delve into the medical libraries, literature, discussion groups, and research every available source to become knowledgeable in his or her own health care success. Assuming that this imperative learning endeavor takes a modicum of intelligence on the part of the patient, I think he or she can stand to hear a medical professional's personal opinion, as long as it's presented as such, without drawing a conclusion that this is the only option available. In fact, I think it's insulting not to share, and serves only to further perpetuate the distance between the vast educated help that the doctor can offer, and the confused and frightened patient.

Tanya. Jones

Portland, Oregon

www.teleport.com/~theguild


Date: Wed, Oct 9, 1996 11:09 PM EDT From: ronb@ieway.com To: DoktorMo@aol.com

Signe is way off base, but she is Politically Correct!

I guess I would like to say that in our coin-operated medical system, I value a good physician who has an opinion! I'm a dialysis patient for 31 years. I don't know exactly when it started but somewhere along the line more and more physicians are not explaining the hazards of a life on dialysis. Patients and families need to be made exquisitely aware of what they are getting into when they embark on the road of dialysis and possibly transplantation. Personal responsibility needs to be stressed, possible complications need to be discussed so patients and families can go into treatment (or refuse treatment!) with their eyes open and never have to go back to the physician and say, "You never told me it would be like this." Granted, a physician can not cover all the possibilities because the avenues and outcomes are so numerous, but almost any nephrologist (and I think this related to most other physicians) who has been around five years has a wealth of knowledge that he or she should be willing to impart, in terms of advise or anecdotal information, thereby characterizing and illuminating what this course of treatment I as a patient am about to embark upon will be like. That's what I want from my doctor: an educated guess. I don't hold him to unreasonable standards (humans make mistakes), I don't expect perfection, I just want the benefit of his knowledge.

I don't want to beat this to death, but I lament the loss of physicians who will take a stand with their patients and say what they feel in their hearts which has been provided by the benefit of their experience. Society (and medicine) has largely gotten away from that I guess, and in my opinion we are a lot more piss-poor because of it. We come together as human beings trying to help each other out.. No one considers doctors "gods" as they used to in the old days, they are fellow beings with knowledge. Impart that knowledge to your patients doc!!, do it in a caring and loving way and you will be appreciated for it.

In the course of my 31 years on dialysis I have met numerous patients who have told me, "I don't like this .I never knew it would be this way. I wish I had died and never started treatment." Most of the patients have been older, some have been blind diabetic amputees, others have been just like me, in relatively good physical health but not coping mentally. DOCTORS, WE NEED YOU!! COME BACK!! Otherwise we are going to drop you like a hot rock and rely completely on the coin-operated Computer Database Diagnostician of the future.

No offense intended.

Ron Bull


Date: Tue, Sep 17, 1996 1:18 AM EDT From: devilbaby@earthlink.net To: DoktorMo@aol.com

By the way, I was so intent on my particular issue that I did not address the larger ones of opinions and patient's "needs" of such. When patient's are struggling with an issue opinions are probably sometimes warranted. But, remember. many patients know the issues and have made their decisions. They may have been on a particular brand of medication that they find works best for them, and need a new physician to prescribe it, not take the position of treating the patient as someone for the physician to force his particular medical bias of "best" medication upon. Medical decisions have been too long identified with "doctor decision making" versus the more needed and appropriate "patient decision" making.

Robyn LCSW


Date: Tue, Sep 17, 1996 12:57 AM EDT From: devilbaby@earthlink.net To: DoktorMo@aol.com

As a person on prozac for a number of years, and successfully so, I have an opinion more case specific than general. I was misdiagnosed by a psychiatrist (even though I sporadically mentioned how depressed I was) and on the wrong medication for three years. Consequently lost ten years to depression vs. seven. As a person who has a chronic condition to manage and as someone who has learned the hard way I do not feel the need to call my doctor for permission to raise or lower my dosage (such as when my mother died). Since I recognize that I am the expert on my depression or medication needs of the moment A doctors recent request to call him vs. raising my dosage irked and frightened me. I know from hard experience that no on else can completely trusted about my depress but me!!!!The implication of his request (and he is not a psychiatrist at that) was that he would be the one to decide whether I was really depressed or not.EXCUSE ME!!!??? I would appreciate it if anyone could comment on this and if my position is a respected one by some in the medical field. (God, I hope so) By, the way the physician who decided he knows better than me know zilch about me--never asking for details of my depression history or self-management knowledge and history.

Robyn


Date: Fri, Jul 19, 1996 8:28 PM EDT From: af485@lafn.org

My opinion is directly opposed to the prior comment! A physician's responsibility lies first of all in informing the patient as completely and thoroughly as he is able to, as far as diagnosis, therapeutic options and prognosis are concerned. However, in my opinion, he has shirked part of his responsibility by NOT providing his personal input. Without this, he becomes nothing more than a sophisticated computer. When a patient asks: "What would you do/prescribe/choose if you had to make this choice for your own parent/child/mate?" a physician should provide an honest answer. Paternalistic? Yes. But a patient visits a physician, instead of studying text books, to get more than information. He wants someone to talk with about agonizing decisions, to bounce his own reactions off another, to look for support or disagreement regarding his wavering indecision. Finally, there is no way that even the best efforts of providing information can transmit all the nuances of knowledge and the insight gained through years of education and years of experience.

Hans G. Engel, M.D.


Date: Wed, May 22, 1996 5:30 PM EDT From: froboz@indirect.com To: DoktorMo@aol.com

I believe physicians best serve their patients' decision making by keeping the process patient-centered, not-physician-centered. This can best be accomplished by actively listening to the patients' issues, reflecting their concerns, drawing out their values, attitudes, motivations, and beliefs, and helping them scope their alternatives (perhaps by giving examples of what others have done in similar situations). In doing this the physician needs to empathize with the difficulties of decision making and the anxieties and fears which accompany it, and to note some of the points the patients may wish to consider. The approach allows the physician to be compassionate, facilitate the patients' decision making process, support their autonomy, but not offer personal opinions or advice. Because of the inherent power-status inequality between physicians and patients, "whatever" a physician says, even if it's only a personal opinion, is likely to be given considerable weight. This situation is ripe for paternalism. When asked what she/he would do, the physician could respond first with an acknowledgment of how tough a decision it is to make and second with an expression of what the physician would consider in making a decision in this situation, touching on areas already highlighted by the patient. Patients may ask personal opinions/advice of physicians for a plethora of reasons: to seek direction, recommendations, clarification of their own thinking, physician's approval et al. Irrespective of patients' motives, physicians should not offer personal opinions when asked, and should keep their mouths shut when not asked. Is this non-directive approach likely to catch on any time soon? Probably not, because it takes more time, is more difficult to do, and isn't as ego-gratifying as offering personal advice.

Signe A. Dayhoff

Tuesday, July 25, 2006

More on the Issue of Infant Male Circumcision

With over 400 comments to the thread on infant male circumcision, it seems that the comments for the last 2 days are not being published on my blog. In response to those who want to keep the discussion going, I have started up this comment page. If Google's Blogger.com ever reestablishes that original page, I would advise not writing further comments there but writing only to this current page to maintain continuity. ..Maurice.

IMPORTANT NEW NOTICE: AS OF DECEMBER 9 2009, NO FURTHER COMMENTS WILL BE PUBLISHED ON THIS THREAD. YOU MAY WRITE COMMENTS, HOWEVER, ON "INFANT MALE CIRCUMCISION: CHAPTER 3" THREAD. ..Maurice.

Monday, July 24, 2006

The Ethics of Assisting a Peaceful Death When There is No Peace

Is there ever a time, is there ever conditions which could lead physicians to a permissible and direct assisting the death of their patient? Read the article by Mary Faith Marshall in the Summer 2006 issue of The University of Minnesota Center for Bioethics “Bioethics Examiner” about the patient deaths at Memorial Medical Center in New Orleans and the accusation by the Louisiana Attorney General of a physician and two nurses as intentionally causing the deaths during the emotional and physical ravages of the consequences of Hurricane Katrina.


Read
Mary Faith Marshall’s thoughts and then come back and write your thoughts here. We don’t know all the facts. We can only imagine. But then, after all is known, could assisting death, under some circumstances, be acceptable? ..Maurice.

Tuesday, July 18, 2006

Embryonic Stem Cell Research Bill and Threat of Presidential Veto

I just can’t understand the logic of President Bush as his spokesman suggests that he will be vetoing the bill passed by House and Senate to support federal funding for new embryonic stem call lines. According to news reports, Tony Snow stated in a press conference today "The simple answer is he thinks murder's wrong, The president is not going to get on the slippery slope of taking something living and making it dead for the purposes of scientific research."

But surely, the President knows that aborting a fetus already developing in the mother’s womb is legal and not murder. On what basis of law or philosophy or science could the President say it is murder to use a embryo not intended for implantation for a public good. That is no way to be potentially beneficent to the billions of living persons simply to protect an already discarded embryo.

Let’s hope he uses common sense and not veto the bill, instead of imposing his personal view on the majority of American’s who support embryonic stem cell research. ..Maurice.

Tuesday, July 11, 2006

Medicalization of GI: Can Conflicts in Gender Identity (GI) Be Considered a Disease?

The following was brought to my attention today and is
extracted from the Obituary Column of the Baltimore Sun:

Dr. John Money, one of the nation's pre-eminent sex researchers who
pioneered the study of gender identity and helped establish Johns Hopkins as
the first hospital in the country to perform adult sex-change operations,
died [recently] He was 84.

His most memorable and criticized work was advocating sex-change operations
for patients confused over their gender, a position that was denounced by
some colleagues who favored counseling instead of surgery. In 1979, Hopkins
announced that it no longer would perform the operations.



For more on Dr. John Money from Wikipedia click here.

However, Money’s death brings up the ethical topic of the medicalization of gender. Do conflicts or uncertainties of gender identity represent a pathologic process, which requires medical treatment as a disease? To obtain more information about gender identity issues go to GIDinfo and specifically for the conflicting views of the medicalization of gender identity “disorder” click
here

When you are through reviewing the subject then come back and write your views here and also tell us specifically what arguments seem the most valid to you. If you already have knowledge about the conflicting views, go ahead and set yours down here but provide us with the basis for what you believe.. then we all will learn. …Maurice..

Monday, July 10, 2006

Bioethics Thinking Small and Missing the Big Picture

I received the following e-mail today by an author who presents a view that would lead me to wonder whether those of us in bioethics are spending too much of our energy of philosophical thought and discussion on what are in fact minor issues and are actually missing the important “big picture”. Read below what H.F.Matare reminds us. I would be most interested to know what you all think.. ..Maurice.



The strong condemnation of the combination of Bio and ethics by a number of people has its base in the philosophical consideration of "human dignity”. Stem cell research e.g. is considered as a manipulation with human embryos, irrespective of the status of development. Frozen, fertilized oocytes are considered "humans" by some ethicists. Such opinions may be conceived as ethical. But can such ethics be considered real, in view of the actual human situation on this planet, where millions of humans flee from overcrowded and underdeveloped regions into the industrial countries, because their multiplication of more than 4%/annum (with doubling times under 17 years) has led to untenable misery. Can one talk about dignity when millions lead a life in squalor and poverty while multiplication continues unabatedly. Or is it dignified to save deformed babies for a life in misery. Are the millions of deserted children in the main towns in South America e.g. who live of theft a life of hopelessness, a sign of the dignity of their parents?- J.Diamond has aptly described human collapse in his recent book under this title and clearly described the untenable human situation, when procreation is religiously sanctified and churches further support multiplication in areas where brain development is missing, to cope with the problems of survival.(SCIENCE 9.9.05 pp 1717-1721: Microcephalin for brain development, uneven distribution)-It is dignified to consider the boundary conditions for a satisfying human existence on this planet. Diamond points out e.g. that a growth of humanity by the same factor as prevailed since 2000 years, for another such period would lead to a human mass greater than the mass of planet earth!!!!-- The general boundary conditions for humanity have also been discussed in H.F.Matare;"Energy, Facts and Future" CRC Press 1989 and in my recent book on Bioethics.
H.F.Matare

Wednesday, July 05, 2006

Male Circumcision: Should It Now Be A Crime?

Male circumcision is without doubt one of the more controversial issues along with abortion within the cultures within the United States. There are ethical, legal, medical, cultural and religious as well as, I presume, political aspects to the issue. This topic was brought up on my blog posting "I Hate Doctors" but I felt it was an important topic to be discussed on a posting more specific to the circumcision issue. Other constructive discussions of "hateful" concerns and experiences about physician behavior can continue to be discussed there but I would like circumcision issues discussed here. I would also appreciate comments and arguments here from those visitors who see some good or value in circumcision or would find defects, legal or ethical, in the law requested below. ..Maurice.



The MGMBill.org, is attempting to get a bill passed in Congress to make male genital circumcision a crime in addition to what many feel to be mutilation acts on females. Below is the proposed congressional bill which the group hopes will become law. According to their website, "the MGM Bill proposal has been submitted to every member of Congress three times: on February 23, 2004, February 28, 2005, and February 6, 2006. In 2006, our state offices also submitted state level MGM Bill proposals to every member in 15 U.S. state legislatures."

Genital Mutilation Prohibition Act

IN THE HOUSE AND SENATE OF THE UNITED STATES

---------------------------------------------------------------

A Bill

Submitted to Congress on February 6, 2006

Entitled the "Federal Prohibition of Genital Mutilation Act of 2006"

Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled, to amend the Female Genital Mutilation Act of 1996 (a) so that boys, intersex individuals, and nonconsenting adults may also be protected from genital mutilation; (b) to increase the maximum punishment of offense to 14 years imprisonment, (c) to include assistance or facilitation of genital mutilation of children or nonconsenting adults as an offense, and (d) to prohibit persons in the U.S. from arranging or facilitating genital mutilation of children and nonconsenting adults in foreign countries.

SECTION 1. SHORT TITLE
This Act may be cited as the "Federal Prohibition of Genital Mutilation Act of 2006".

SECTION 2. TITLE 18 AMENDMENT
(A) IN GENERAL.--Title 18, Part I, Chapter 7, Section 116 of the United States Code is amended by revising the text to read as follows:

"116. GENITAL MUTILATION
"(a) Except as provided in subsection (b), whoever knowingly circumcises, excises, cuts, or mutilates the whole or any part of the labia majora, labia minora, clitoris, vulva, breasts, nipples, foreskin, glans, testicles, penis, ambiguous genitalia, hermaphroditic genitalia, or genital organs of another person who has not attained the age of 18 years or on any nonconsenting adult; whoever prematurely and forcibly retracts the penile or clitoral prepuce of another person who has not attained the age of 18 years or on any nonconsenting adult, except to the extent that the prepuce has already separated from the glans; whoever knowingly assists with or facilitates any of these acts; or whoever arranges, plans, aids, abets, counsels, facilitates, or procures a genital mutilation operation on another person outside the United States who has not attained the age of 18 years or on any nonconsenting adult outside the United States shall be fined under this title or imprisoned not more than 14 years, or both.

"(b) A surgical operation is not a violation of this section if the operation is (1) performed on a person who has not attained the age of 18 years and is necessary to the physical health of the person on whom it is performed because of a clear, compelling, and immediate medical need with no less-destructive alternative treatment available, and is performed by a person licensed in the place of its performance as a medical practitioner; (2) performed on an adult who is physically unable to give consent and there is a clear, compelling, and immediate medical need with no less-destructive alternative treatment available, and is performed by a person licensed in the place of its performance as a medical practitioner; or (3) performed on a person in labor or who has just given birth and is performed for medical purposes connected with that labor or birth because of a clear, compelling, and immediate medical need with no less-destructive alternative treatment available, and is performed by a person licensed in the place it is performed as a medical practitioner, midwife, or person in training to become such a practitioner or midwife.

"(c) In applying subsection (b), no account shall be taken of the effect on the person on whom the operation is to be performed of any belief on the part of that or any other person that the operation is required as a matter of custom or ritual.

(B) CLERICAL AMENDMENT.--The table of sections at the beginning of Chapter 7 of Title 18, Part I, of the United States Code, is amended by revising Section 116 to read "116. Genital mutilation."

SECTION 3.INFORMATION AND EDUCATION REGARDING GENITAL MUTILATION
(A) IN GENERAL. -- The Secretary of Health and Human Services shall carry out the following activities:

(1) Compile data on the number of persons of all sexes living in the United States who have been subjected to genital mutilation (whether in the United States or in their countries of origin), including a specification of the number of children under the age of 18 who have been subjected to such mutilation.

(2) Identify communities in the United States that practice genital mutilation, and design and carry out outreach activities to educate individuals in the communities on the physical and psychological effects of such practice. Such outreach activities shall be designed and implemented in collaboration with representatives of the ethnic groups practicing such mutilation and with representatives of organizations with expertise in preventing such practice.

(3) Develop recommendations for the education of students of schools of medicine and osteopathic medicine regarding genital mutilation and complications arising from such mutilation, as well as complications arising from premature forcible retraction of the prepuce. Such recommendations shall be disseminated to such schools.

(B) IN GENERAL. -- The President shall carry out the following activities:

(1) Seek to end the practice of genital mutilation worldwide through the active cooperation and participation of governments in countries where genital mutilation takes place.

(2) Steps to end the practice of genital mutilation should include--

(a) encouraging nations to establish clear policies against genital mutilation and enforcing existing laws which prohibit it;

(b) assisting nations in creating culturally appropriate outreach programs that include education and counseling about the dangers of genital mutilation to people of all ages; and

(c) ensuring that all appropriate programs in which the United States participates include a component pertaining to genital mutilation, so as to ensure consistency across the spectrum of health and child related programs conducted in any country in which genital mutilation is known to be a problem.

(C) DEFINITIONS. -- For purpose of this Act, the term "genital mutilation" means the removal or cutting (or both) of the whole or part of the clitoris, labia minora, labia majora, vulva, breasts, nipples, foreskin, glans, testicles, penis, ambiguous genitalia, hermaphroditic genitalia, or genital organs. The term "premature forcible retraction of the penile or clitoral prepuce" means forced retraction of the prepuce from the glans, except to the extent that the prepuce has already separated from the glans. The term "prepuce" means foreskin. The term "adult" means a person who has attained the age of 18 years. The term "nonconsenting" means not wishing to undergo genital mutilation.

SECTION 4. EFFECTIVE DATES
Section 2 of this Act shall take effect immediately after the date of the enactment of this Act. Section 3 of this Act shall take effect immediately after the date of the enactment of this Act, and the Secretary of Health and Human Services and the President shall commence carrying it out not later than 90 days after the date of the enactment of this Act.


IMPORTANT NOTICE: NO FURTHER POSTINGS HAVE BEEN ALLOWED ON THIS THREAD SINCE 2006. HOWEVER, YOU CAN CONTINUE WRITING ON THIS TOPIC BY GOING TO THE "INFANT MALE CIRCUMCISION: CHAPTER 3" THREAD.