Male Circumcision

Ritual circumcision has not been an issue in Finland until very recently. The number of immigrants has always been small compared to, say, the other Nordic countries, and minorities that practice circumcision have been, from a public and legislative point of view, insignificant. The whole issue of ritual circumcision of females became widely known by the Finnish public only in the 1990s, when we received a growing number of immigrants from Somalia, many of the girls among whom had been circumcised in their home country. The attitudes of authorities and the public alike toward female circumcision has been very negative. It is not considered acceptable in any circumstances.

The small Jewish community in Helsinki has always practiced male circumcision, but this has been no major concern. These operations have been mostly carried out by Jewish surgeons in private hospitals, and the few that have been performed in public hospitals in other parts of the country have gone unquestioned. The small number of male circumcisions were tacitly approved. It was only in the 1990s, when the number of poor Muslim immigrants increased, that male circumcision became a problem for the public health authorities. Some physicians working with immigrants were unsure whether such procedures, without clear medical indication, should be allowed at all, especially when consent cannot be obtained. There were also questions raised about whether such operations should be performed in public hospitals and paid for with public funds.

After these issues were raised, the Deputy Parliamentary Ombudsman declared that public hospitals cannot be considered to have a duty to perform male circumcisions because these operations cannot be perceived as treatment or prevention of disease. She also made reference to the Convention on Human Rights and Biomedicine, which states, “an intervention may only be carried out on a person who does not have the capacity to consent, for his or her direct benefit.”³

However, she remained unclear about whether hospitals have the right to perform these operations. Her main conclusion seemed to be that circumcision should not be performed in public hospitals before the boys themselves are old enough to give a valid informed consent to the operation.

In their statement in 1999, the National Advisory Board on Health Care Ethics could not come to an agreement on the matter, either, but maintained that ritual circumcision of Jewish and Muslim boys should not be made illegal. There were, however, also dissenting voices who argued that for an invasive procedure with certain risks, when consent cannot be obtained and no medical benefit is expected, the good of the child should be the first consideration, and that this would mean not tolerating male circumcision.⁴

The issue was brought back into the limelight after the University Hospital of Kuopio decided not to perform circumcisions, and when, shortly after, boys suffering from bleeding and infections after circumcisions had been performed outside the hospital were admitted to care.

After the incidents in Kuopio, the Ministry of Health and Social Services, together with the local and regional authorities, issued a communication to public hospitals encouraging them to perform circumcisions on Jewish and Muslim boys. The main aim was to avoid these operations taking place outside healthcare services. Another argument for performing the operations relies on the right to cultural practices and freedom of religion. One of the spokespersons for the practice compared doctors who refuse to perform circumcisions to priests who refuse to baptize children. This analogy is not without fault, but it speaks volumes about the profundity of the dispute.

Currently, male circumcisions for religious reasons are performed in a few public hospitals with public funds. In some hospitals, however, the pediatric surgeons refuse to perform the operation without an obvious medical indication.

Assisted Reproduction, Embryos, and Stem Cell Research

In 2003 Finland is still without a law on assisted reproduction. The proposal given to the Parliament last year, which included a ban on surrogacy and very strict rules for single women's access to fertility treatments, was tossed between the Legal Affairs Committee and the Parliament's Grand Committee and, finally, withdrawn. It was the Legal Affairs Committee's insistence that a child should always have a right to a mother and a father, which would have made single women's and lesbians access to treatments virtually impossible, that was unacceptable to the Government, and the law, again, waits to be drafted.

There is strong political pressure to quickly come up with a law on assisted reproduction, because such a law is required by the Convention on Human Rights and Biomedicine.⁵

Additionally, professionals working in the field have expressed their unease about being forced, without the guidance of a legal framework, to make up their own rules as situations come up. Their work is partly regulated by the Act on Medical Use of Human Organs and Tissues⁶ and the Medical Research Act,⁷ but questions like who should have access to fertility treatments and on what grounds are now left, for the most part, for the professionals themselves to decide.

In the absence of a law on assisted reproduction, it is no small wonder that stem cell research, especially embryonic stem cell research, has caused a lot of discussion in research ethics committees. Legally speaking, research on embryos is allowed, provided that the embryos have not been created for this purpose only (i.e., they must be “spare” embryos from fertility treatments), they are less than 14 days old (the time they are kept frozen is not counted), informed consent from the persons whose gametes are involved is obtained, and the National Authority for Medicolegal Affairs has approved the research. Further, it is not allowed to keep the research embryos alive for more than the 14 days during which research is allowed.⁸

Currently, embryonic stem cell research is practiced only at one institution, the Family Federation of Finland. The Federation uses surplus embryos that can no longer be used for fertility treatments. After the storage time has ended, the persons from whose gametes the embryos were created are contacted and their informed consent is sought. As there is no law on stem cell research, there are no legal regulations about what sort of research is allowed, this being left to the National Authority for Medicolegal Affairs and relevant ethics committees to decide.

With this issue there are also, however, political reasons to have a law on stem cell research. In the European Union, there are constant attempts to regulate embryonic stem cell research. And the European Commission, an important sponsor of research in Europe, has introduced strict guidelines on E.U.-funded embryonic stem cell research. Among the restrictions is refusal to fund research that uses embryos created after June 27, 2002.⁹

This has no immediate effect on research done in Finland because the embryos currently used at the Family Federation of Finland are older than this, but there have been questions regarding the justification of such time limits in general and concerns about their impact on future research.

Medical Research

The already-mentioned Medical Research Act, which came into force on November 1, 1999, has given rise to an unexpected new problem. The law lists general conditions under which medical research can be conducted and gives specific rules regarding consent and research on minors, pregnant women, prisoners, embryos, and fetuses. It also regulates the composition and duties of research ethics committees. There were, of course, research ethics committees in Finland prior to the act, but the new law specified their role. What is unclear about the law, however, is what exactly is meant by medical research. According to the act,

The Finnish expression for the “intervention in the integrity”¹¹

carries the same type of ambiguity as its unofficial English translation—the Finnish phrase implying perhaps even more straightforwardly that the scope of the act is physical intervention. The Medical Research Act does not further specify what is meant by “intervention in the integrity,” and in a codified law system there are very few other places to look for interpretation. For the most part, the interpretation in research ethics committees has been that their duty is to oversee medical research that involves physical touching.

In the early national meetings of regional ethics committees, it has, however, become clear that the interpretation of the scope of the act varies between, and within, the committees. Consider, for instance, a research proposal in which the research team is set to compare the quality of life of teenagers with chronic diseases to controls of the same age but without such a medical condition. Suppose further that the research includes in-depth interviews, during which questions will be asked about the research subjects' self-image, personal relationships, and whether they have considered killing themselves. Another example could be an ethnographic study on hospices, in which the researcher participates in the daily hospice life as a volunteer.

Both of our examples illustrate that in a medical setting there can be research that does not include physical touching but that could still, in a wider understanding of the phrase, be considered to intervene in the integrity of the study subjects and to involve other sensitive issues. If the law is interpreted so that research ethics committees should only deal with research including physical touching, it is unclear who, then, should consider the acceptability of research in medical settings that does not include this. A further problem is that if the regional ethics committees do not agree on the scope of the law, then research teams and study subjects in different parts of the country are put in unequal positions.

Challenges Ahead

Apart from the specific problems mentioned, there are increasing concerns regarding the state of the Finnish healthcare system as a whole. Scarcity of funds and vast advances in medical technology (creating new and expensive treatments and methods of diagnosis) have led to queues for special care, unequal distribution of healthcare services around the country, shortage of staff in healthcare units, and questions concerning the role and function of a tax-funded available-to-all healthcare system in general. These are problems not unique to Finland and are felt largely the same way, for instance, in the other Scandinavian welfare states.¹²

It is to be assumed that the big healthcare ethics debate of the decade will take place on the political level and concern the possibility of reorganizing the Finnish healthcare system.

In terms of more specific themes, euthanasia and other end-of-life issues continue to provoke discussion, the deliberations on embryonic stem cell research have opened up some of the old abortion controversies, and, we predict, the debate on a large-scale genetic databank may soon hit the headlines.