ABSTRACT: Sterilization, like any other surgical procedure, must be carried out under the general ethical principles of respect for autonomy, beneficence, and justice. Women requesting sterilization should be encouraged to discuss their decision and associated issues with their husbands or other appropriate intimate partners. The physician who objects to a patient's request for sterilization solely as a matter of conscience has the obligation to inform the patient that sterilization services may be available elsewhere and should refer the patient to another caregiver. The presence of a mental disability does not, in itself, justify either sterilization or its denial. When a patient's mental capacity is limited and sterilization is considered, the physician must consult with the patient's family, agents, and other caregivers in an effort to adopt a plan that protects what the consulted group believes to be the patient's best interests while, at the same time, preserving, to the maximum extent possible, the patient's autonomy. .
*Update of "Sterilization of Women, Including Those With Mental Disabilities" in Ethics in Obstetrics and Gynecology, Second Edition, 2004.
Sterilization, like any other surgical procedure, must be carried out under the general ethical principles of respect for autonomy, beneficence, and justice. Special ethical considerations are imposed by the unique attributes of sterilization. The procedure usually is done not for medical indications but electively for family planning. It may have a significant impact on individuals other than the patient, especially her partner. It is intended to be permanent, although techniques are available to attempt reversal or circumvent sterility. Finally, sterilization affects procreation and, therefore, may conflict with the moral beliefs of the patient, her family, or the physician. When the patient has diminished mental abilities or chronic mental illness, even more stringent ethical constraints apply.
General Ethical Principles
Under the principle of respect for autonomy, patients have the right to seek, accept, or refuse care. Respecting the patient's autonomy means that the physician cannot impose treatments. It does not mean that the physician must provide treatment, especially if the physician considers it inappropriate or harmful (eg, an 18-year-old patient who asks to undergo sterilization).
Sterilization is for many a social choice rather than purely a medical issue, but all patient-related activities engaged in by physicians are subject to the same ethical guidelines. Patients sometimes request a physician's counsel in deciding whether to request sterilization. Physicians should be cautious in giving advice and making recommendations that go beyond health-related issues, even though nonmedical factors might be the most compelling for the patient. It may be difficult for the physician to address nonmedical issues without bias. Also, the physician may not have a full understanding of the patient's situation. However, it is entirely appropriate for the physician to assist the patient in exploring and articulating the reasons for her decision.
Although a woman's request for sterilization may conflict with the physician's medical judgment or moral beliefs, the patient's values and request cannot be dismissed or ignored. In such cases, the physician has an obligation to inform the patient of his or her professional recommendation and the medical reasons for it. The physician remains responsible for his or her actions and generally is not obligated to act in violation of personal principles of conscience, but the patient should be informed when personal principles limit action or treatment. If the patient still desires sterilization, the physician who objects solely as a matter of conscience has the obligation to inform her that sterilization services may be available elsewhere and should refer her to another caregiver. The physician's values; sense of societal goals; and racial, ethnic, or socioeconomic issues should not be the basis of a recommendation to undergo sterilization.
Sterilization requires the patient's informed consent for ethical and medical–legal reasons. The physician performing the procedure has the responsibility of ensuring that the patient is properly counseled concerning the risks and benefits of sterilization. The patient should receive comprehensive and individualized counseling on reversible alternatives to sterilization (1). The procedure's intended permanence should be stressed, as well as the possibility of future regret. An estimate of the procedure's failure rate and risk of ectopic pregnancy should be provided. A variety of patient education materials are available to assist in preoperative counseling, but it is essential for the patient to be given the opportunity to discuss all relevant issues with her physician and to ask questions.
The physician should be familiar with any laws and regulations that may constrain sterilization, such as limitations on the patient's age and requirements for the consent process. The physician should inform the patient that insurance coverage for sterilization is variable so that she can discuss this issue with her insurer.
Specific Ethical Issues
Because sterilization may have important effects on individuals other than the patient, women requesting sterilization should be encouraged to discuss the issues with their husbands or other appropriate intimate partners. In many cases, it is preferable for the male partner to be sterilized. It may be helpful for the physician to counsel the partner directly, with the patient's consent.
Hysterectomy solely for the purpose of sterilization is inappropriate. The risks and cost of the procedure are disproportionate to the benefit, given the available alternatives. In disabled women with limited functional capability, indications for major surgical procedures remain the same as in other patients. In all cases, indications for surgery must meet standard criteria, and the benefits of the procedure must exceed known procedural risks. Disabled women with limited functional capacity may sometimes be physically unable to care for their menstrual hygiene and are profoundly disturbed by their menses. On occasion, such women's caretakers have sought hysterectomy for these indications. Hysterectomy for the purpose of cessation of normal menses may be considered only after other reasonable alternatives have been attempted.
Women may be vulnerable to various forms of coercion in their medical decision making. For example, the withholding of other medical care by linking it to the patient's consent to undergo sterilization is ethically unacceptable. Laws, regulations, and reimbursement restrictions concerning sterilization have been created to protect vulnerable individuals, including those with mental disabilities, from abuse. However, sterilization should not be denied to individuals simply because they also may be vulnerable to coercion. Physicians caring for patients who request or require procedures that result in sterilization may find themselves in a dilemma when legal and reimbursement restrictions interfere with a patient's choice of treatment. Rigid timing and age requirements can restrict access to good health care and result in unnecessary risk (2). Physicians are encouraged to seek legal or ethical consultation or both whenever necessary in their efforts to provide care that is most appropriate in individual situations.
At a public policy level, medical professionals have an opportunity to be a voice of reason and compassion by pointing out when legislative and regulatory measures intended to be safeguards interfere with patient choice and appropriate medical care.
Special Considerations Concerning Patients With Mental Disabilities
As used in this Committee Opinion, the term "women with mental disabilities" refers to individuals whose ability to participate in the informed consent process is, or might be, limited and whose autonomy is, or might be, thereby impaired. Such individuals constitute a heterogeneous group, including those with varying degrees of presumably irreversible "mental retardation" as well as those with varying types and degrees of "chronic mental illness." Some of these illnesses are reversible to varying degrees and for varying periods. The concept of "chronically and variably impaired autonomy" has been proposed to describe such situations (3).
Physicians who perform sterilizations must be aware of widely differing federal, state, and local laws and regulations, which have arisen in reaction to a long and unhappy history of sterilization of "unfit" individuals in the United States and elsewhere. The potential remains for serious abuses and injustices. Individuals who are capable of reproducing and parenting without a presumptive risk of child neglect or abuse may be deprived of their procreative rights simply because they carry a label, such as mild retardation, that suggests an inherent unfitness to parent. The implications of this labeling process for reproductive rights should be examined as thoroughly and objectively as possible before making a decision about sterilization.
Conversely, individuals for whom pregnancy is a serious burden or harm may be denied the opportunity for a full range of contraceptive options. For example, federal funds may not be used for the sterilization of "mentally incompetent" or "institutionalized" individuals (2). Physicians always should have the maximum respect for patient autonomy, and the presence of a mental disability does not, in itself, justify either sterilization or its denial.
Determination of Ability to Give Informed Consent
Before carrying out any surgical procedure, the physician has the important responsibility of ascertaining the patient's capacity to provide informed consent. It may be difficult to be sure that patients with normal intellectual function understand the complexities of some situations; when the patient has a mental disability, the task is more difficult and the responsibility is more challenging.
Evaluating a mentally impaired patient's ability to provide informed consent is seldom straightforward (4). For example, although degrees of mental retardation have been defined according to intelligence quotient, there is no direct relationship between such diagnostic categories and the capacity to consent. Among the issues that may need to be considered in the assessment are the patient's language and culture, the quality of information provided (clarity, completeness, and lack of bias), the setting of counseling (privacy and comfort), and possible fluctuations in the patient's comprehension. Such fluctuations may result from various stressors and medications. Multiple interviews over an adequate period may be required. Obtaining the assistance of professionals trained in communicating with mentally disabled individuals is essential. These professionals may include special educators, psychologists, nurses, attorneys familiar with disability law, and physicians accustomed to working with mentally disabled patients.
The process of evaluating a patient's ability to give informed consent may be set forth in laws of the jurisdiction involved, and legal requirements for the determination of competence vary greatly. The concept of legal competence is quite complex. Standards for the definition of competence may vary with the specific purpose (eg, marriage; making a will; consenting to or refusing lifesaving treatment; or, as in the case of sterilization, consenting to elective surgery). Court approval of sterilization may be required by law or may be necessary in difficult cases because of disagreement among the patient's caregivers and consultants. In most jurisdictions, court action is not required to carry out a sterilization procedure if there is agreement among these consultants that a nonminor is capable of consenting. Certain jurisdictions may not recognize guardian consent for sterilization of minors with mental disabilities under any circumstances. Whether or not recourse to the courts is necessary, every effort should be made to conduct the determination of competence fairly and to preserve autonomy.
Ethical Issues When the Patient Cannot Give Informed Consent
When the patient has been determined to be irreversibly incapable of participating in all or part of the informed consent process, others must make beneficence-based decisions regarding medical treatment. Such a determination is relatively uncommon. Even in these situations, it often is possible and highly desirable to obtain at least the patient's assent. The initial premise should be that nonvoluntary sterilization generally is not ethically acceptable because of the violation of privacy, bodily integrity, and reproductive rights that it may represent.
Physicians and other caregivers should avoid paternalistic decisions in all cases in which the individual may be capable of participating to some degree in decisions regarding her care. The following recommendations are based in part on those of McCullough et al (3). They do not apply to mentally impaired individuals who can participate in the consent process
For patients with chronically and variably impaired autonomy, initial efforts should be directed toward restoring decision-making ability by such means as adjustment of medication and avoidance of stressors. This may allow the patient to exercise full autonomy. For cases in which these efforts fail, the following guidelines are recommended:
- Efforts should be made to conform to the patient's expressed values and beliefs regarding reproduction. Such information may be available from interviewing the patient, her family, caregivers, and others in her environment. If possible, alternatives (including no action) consistent with her beliefs, medical condition, and social situation should be presented to decision makers.
- Physicians should be aware of the possibility of undue pressure from family members whose interests, no matter how legitimate, may not be the same as the patient's. When appropriate, the patient should have the opportunity to be interviewed without family members present.
- Noninvasive modalities designed to assist family members and other caregivers with setting behavioral limits should be considered as alternatives to sterilization. These resources may include socialization training, sexual abuse avoidance training, supportive family therapy, and sexuality education.
- Consideration should be given to the degree of certainty of various adverse outcomes. For example, given the patient's living circumstances, how likely is it that she might be sexually exploited? Given available knowledge concerning her reproductive potential (ovulatory status and tubal patency), how likely is it that she will become pregnant? How likely are adverse medical or social consequences from a pregnancy? Because it is uncommon for such risks to be reliably predicted, it may be preferable to recommend a reversible long-term form of contraception, such as an intrauterine device, long-term injectable progestin, or long-acting subdermal progestin implants (if available), instead of sterilization. In most cases, the chosen method of contraception should be the least restrictive in preserving future reproductive options. This is especially true when a major factor in the request for sterilization is concern about burdens for others. At the same time, risks and inconveniences of contraception over a long period, as compared with a single, relatively simple, and definitive surgical procedure, should not be ignored.
- The well-being of a child potentially conceived also should receive consideration.
Sterilization is an elective procedure with permanent and far-reaching consequences. Physicians who perform sterilization have ethical responsibilities of the highest order to counsel patients fully and without bias. Physicians must assess thoroughly the capacity of patients with impaired mental abilities to participate fully in the informed consent process. When this capacity is limited, the physician must consult with the patient's other caregivers in reaching a decision, which is based on the patient's best interests and preserves her autonomy to the maximum extent possible. In difficult cases, a hospital ethics committee may provide useful perspectives.
- Benefits and risks of sterilization. ACOG Practice Bulletin No. 46. American College of Obstetricians and Gynecologists. Obstet Gynecol 2003;102:647–58.
- Sterilization of persons in federally assisted family planning projects. 42 C.F.R. § 50 Subpart B (2006).
- McCullough LB, Coverdale J, Bayer T, Chervenak FA. Ethically justified guidelines for family planning interventions to prevent pregnancy in female patients with chronic mental illness. Am J Obstet Gynecol 1992;167:19–25.
- Appelbaum PS, Grisso T. Assessing patients' capacities to consent to treatment [published erratum appears in N Engl J Med 1989;320:748]. N Engl J Med 1988;319:1635–8.