In the presented case, the autoptic and histological findings where suggestive for a hemorrhagic shock occurred after a “domestic” NMC.

The aim of circumcision is the removal of the preputial skin in order to keep the glans uncovered. Even though NMC is a daily performed procedure all over the world, from a forensic point of view the fatal cases resulting from postoperative complications are rarely described in literature and are generally related to procedures performed by inexperienced or non-medical personnel [10, 13, 15, 16].

The case described by Hiss et al. [15] also concerned a newborn who, after a ‘ritual’ circumcision performed in a domestic environment, developed a severe and ultimately fatal hemorrhagic shock. In that case, however, the histological investigations revealed a hepatopathy that contributed to the determination of the hemorrhagic shock.

Cohen et al. [17], reported a case of hemorrhagic shock after circumcision given to a severe congenital Factor XIII deficiency.

In our case, an analysis of the available data, did not reveal any previous condition that could have influenced the fatal outcome, which was therefore entirely attributable to the ‘’surgical’’ procedure and the conspicuous blood loss that followed.

The fundamental forensic aspect of the presented case to be considered is the reconstruction of the pathophysiological cascade that led to death.

Unlike adults, in neonatal population, the blood loss rates suggestive for hemorrhagic shock are not defined and they are usually expressed, as suggested by some authors, as a percentage of total circulating volume: a blood loss below 15% of the total volume usually demonstrates only mild symptoms such as tachycardia or anxiety (Class I); by a loss between 15 up to 25%, oliguria, mild tachypnea, irritability, and mottled cool extremities can be observed, as early signs of diminished end organ perfusion (Class II); in Class III, corresponding to a loss between 26 and 39%, patients show significant tachycardia, hypotension, irritability (and even lethargy), pale extremities and develop metabolic acidosis; if the loss is greater than 40% total blood volume (Class IV), they become lethargic or may lose consciousness and show a severe tachypnea and tachycardia, significant hypotension and acidosis, as well as cyanosis and anuria, as a result of the mismatch.

Regarding our case, since the circulating blood volume cannot be precisely quantified, it can be calculated according to scientifically accepted estimates and formulas, based on weight and height [18].

In the present case, the circulating blood volume could be estimated within a range of approximately 230.75–356.46 ml. Consequently, it was therefore possible to consider that the onset of a severe hemorrhagic shock beyond stage IV of the above-mentioned classification, could be the consequence of the rapid blood loss of at least 92.3 to 142.59 ml.

It should be however underlined that these values are only estimates, because in the case presented it was not possible, based on the evidence available, to estimate more accurately the extent of the blood loss suffered by the newborn or the precise timing of the onset of bleeding.

In accordance with the literature, the incidence of bleeding during circumcision varies from 0.1% up to 35% [11] and this appeared to be significantly higher if the NMC is performed after the 4th day of life [19].

In this frame, Edler et al. [2] have reported several cases of complications, including 4 cases of hemorrhagic shock (one of whom resulting in death) and argued that given the frequence of potentially fatal complications, NMC should be performed only by medical trained professionals and in hospitals with 24-h emergency departments.

Mano et al. described the characteristics and outcomes of post-ritual circumcision bleeding complications, as well as the short-term outcome [20], suggesting the indication for admission in circumcised children presenting active bleeding at the ER.

Another factor to be considered in the determinism of death in our case is the possible delay in transferring the infant to hospital which may also have played a role.

Given the possibility of potentially fatal complications, a number of authors, as well as jurists and bioethicists, have argued that performing circumcision in healthy individuals without medical indications raises an ethical and medico-legal issue, since it must be considered that in such cases it is a surgical procedure performed on a structurally healthy individual without any health or preventive indication and practiced on minors, thus without the consent of the person concerned [4, 16, 21,22,23].

In this frame, medical and academic associations have no uniform agreement, and the preventive effectiveness of its execution is still debated and controversial [24].

In the U.S., Medicaid (the State-level Insurance) has defunded the coverage of NMC after the AAP indicated that the procedure, due to a lack of evidence, was not essential to the child’s well-being and that the decision was best left to parents but resulting to a decrease in frequency of the number of prophylactic circumcisions [25, 26].

Later in 2012, the American Academy of Pediatrics (AAP) stated that the benefits, in terms of prevention, of routinary circumcision outweighed the risks [27].

On the other hand, the British Medical Association (BMA) asserts that circumcision for purely prophylactic or ritual purposes is not automatically justified by parental consent and urges doctors to inform parents of the issues involved in an invasive medical operation [16].

This controverted efficacy and legitimacy of the procedure therefore led some Countries (e.g. Norway) [23] to consent health professionals the possibility to express conscientious objection to the procedure.

Indeed, the legislation of many countries, moreover, prohibits body modification even in the presence of valid informed consent.

In 2007 an Italian Court [16], emphasized that thought male circumcision constitutes a violation of the psychophysical integrity of a subject who is generally unable to express his consent effectively, it has long been amply accepted by Western custom and culture. However, the same Court also ruled that NMC was a medical act that necessarily had to be performed by medical personnel, according to the Italian Law and that it must be performed in accordance with good clinical practice.

Later, in 2012 a sentence of a German Court, by considering the legal aspects of ritual circumcision, ruled that non-therapeutic circumcision constitutes a bodily assault that violates the child’s right to autonomy and self-determination and that the procedure should be delayed until an age at which the boy can consent on his own [28].

Conclusively, in view of the possibility of complications and fatal outcome, a neonatal circumcision, whatever its reason, takes on the character of medical procedure and should be performed only in medical and safe environment.

Moreover, since this procedure is performed on subjects incapable of expressing valid consent, restricting theoretically their right to self-determination, further ethical and legal reflection about the evaluation of the lawfulness of this practice on minors should be consequently appropriate.