To the Editor: While I generally applaud the comments on phimosis in Dewan's recent editorial,1 there are two points on which I would take issue with him — one historical, one ethical.

Firstly, the incidence of circumcision in Britain never reached anything like 95%, and most of the decline in the practice occurred in the 1940s. According to surveys in the 1940s and 1950s,2 even at the height of its popularity, circumcision was performed in only 30%–40% of British boys. Circumcision was more likely as parental income and educational level rose — its incidence could be up to 50% among public school boys, but only 20% among working class and rural boys.5 A survey of boys born in 1946 found that only 24% were circumcised, but the class differential was striking — 39% among professionals but only 22% among unskilled workers.5

One must conclude that circumcision never affected more than a minority of British males.

Secondly, I would question Dewan's remark that "we should respect the view of parents who regard circumcision as good treatment for their child, given certain provisos." This appears to suggest that a physician should agree to circumcise a boy, even in the absence of medical need, so long as he or she has made persistent parents aware of other options and provided them with correct information about the prepuce.

There are obvious ethical difficulties with this position, as it gives greater weight to the wishes of the parents than to the best interests of the boy. If there is no medical reason for the boy to be circumcised, circumcision is not in his best interests. As the physician's prime responsibility is to the health of the patient, it would appear to be his or her duty to decline to carry out the surgery and instead give the parents sufficient information to enable them to look after the child and his penis.6

I agree with Dewan that physicians should respect parents' opinions, but not that they should acquiesce to their wishes, if these are not in the best health interests of the child. Instead, I would agree with the suggestion of Spilsbury et al in the same issue of the Journal,7 that "improved education for physicians, and perhaps parents, with regard to foreskin development and management, is required."