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September 4, 2002

Beatrice's Choice

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JAMA. 2002;288(9):1135. doi:10.1001/jama.288.9.1135-JMS0904-6-1

Beatrice did not greet me as I walked into the exam room, and I knew something was wrong. "I'm worried. I only think about one thing," she began. "When I return to Sudan I must be circumcised. But I fear the pain, and I have seen infection kill my cousins. I want you to perform my circumcision."

Almost before the magnitude of her request hit me, an excuse leaped out of my mouth, "But I don't do that—I've never performed a female circumcision before."

"But you can help me," she replied quietly.

"Who told you that you must be circumcised?" I wondered aloud.

"I told myself that I must be circumcised," Beatrice answered.

"But do you want to be circumcised?" I challenged, hoping that someone forced this on her.

"I cannot carry my head proudly if I return to my people uncircumcised and unmarried at 18. They'll laugh," she explained.

"Beatrice, I can't consent to do a surgery on you that I do not know you have chosen. Is it your desire to be circumcised?" I asked.

"Americans value their personal choices. The right to choose overwhelms me. Our ways, our people, our culture will disappear if we do not let our ancestors choose our path. I have known my choice since being a little girl. As little girls, we played by pretending that our turn had come. What will be said of me if I am not circumcised?"

"Yes, but I will cause you pain and . . ." I argued, but Beatrice interrupted, "Doctor, that pain is my duty to bear as a woman."

I explained that I was unwilling to surgically remove parts of her body without medical cause. I was frustrated that she could not see the violence of this procedure nor the bondage of being marked as tribal property. Incredulous, but wanting to understand her perspective, I asked why she wanted the circumcision.

"I want a man from my tribe to marry me," Beatrice explained, "and no decent man will take me as his bride now. After circumcision, I will please my husband. If I refuse, my father will not receive the bride price he deserves. Circumcision will mark me as a woman."

She saw two choices: circumcision performed by me or by a village elder. I saw two different ones: to accept or to refuse circumcision.

I saw a potentially liberated, revolutionary woman in charge of her own body. She saw an ancestor willing and eager to carry on her people's traditions. I mentioned I had physician friends in Sudan who were advocating abolishing the practice and that she could find ways to avoid having the procedure done.

"Doctor, that is not my fight. We need your immunizations, food, and education. We do not need your traditions. But, I would like your help to get a circumcision. Other tribes' mark with tattoos, piercings, or cuttings. Our mark is circumcision. It defines us as women of our tribe. The only reason we do not circumcise with anesthetic and clean blades is because we cannot afford them. Do not ask me to rebel against my people. I would have no home."

I hesitated. "If I were to give you the anesthetic, a clean blade, antibiotics, bandages, and suture, could your village elder use them?"

"If you will not perform my circumcision then I would appreciate these things," Beatrice answered.

I reasoned that giving her these things still left her the option of refusing circumcision. But as I gathered the sterile blade, topical anesthetic, suture, and bandage, and wrote the prescription for antibiotics, I couldn't completely escape the sense that I had betrayed her and myself. I tried again to convince myself that I had washed my hands of her blood.

As Beatrice left the exam room, I knew that I had made the right decision. I did what I could to stop her, and when I couldn't, I fulfilled my duty to help her.

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2003 John Conley Ethics Essay Contest for Medical Students

You have two patients: a mother and her adult daughter. The mother has begun to show signs of early Huntington disease (HD). A test for the genetic mutation causing HD confirms your clinical suspicion. You have counseled the mother that her daughter's risk of carrying the genetic mutation is 50%, but the mother has refused to discuss the issue with her daughter. She has also forbidden you to do so because she doesn't want her daughter to be burdened with the knowledge that she might get HD. The daughter has told you recently that she is thinking of starting a family. She knows nothing about the family history of HD because her mother is the only source of information. The HD mutation is autosomal dominant and 100% penetrant. What do you do? What are your obligations to your two patients? What ethical considerations should be taken into account?

Entries must be postmarked by February 1, 2003, and sent to Conley Essay Contest, c/o MSJAMA, 515 N State St, Chicago, IL 60610. The author(s) of the best essay(s) will be awarded $5000 or a portion thereof. More information about the contest is available online at http://www.msjama.org.