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 asso- ciated 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 fam- ily, agents, and other caregivers in an effort to adopt a plan that protects what the con- sulted group believes to be the patient’s best interests while, at the same time, preserving, to the maximum extent possible, the patient’s autonomy.
Committee on Ethics
Reaffirmed 2009
Number 371 • July 2007
The American College of Obstetricians and Gynecologists
Women’s Health Care Physicians
Sterilization, like any other surgical proce- dure, must be carried out under the general ethical principles of respect for autonomy, beneficence, and justice. Special ethical con- siderations are imposed by the unique attrib- utes of sterilization. The procedure usually is done not for medical indications but elective- ly for family planning. It may have a signifi- cant 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 procre- ation 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 auton- omy means that the physician cannot impose treatments. It does not mean that the physi- cian must provide treatment, especially if the physician considers it inappropriate or harm-
ful (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 recom- mendations 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 non- medical issues without bias. Also, the physi- cian 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 rea- sons for her decision.
Although a woman’s request for steriliza- tion may conflict with the physician’s medical judgment or moral beliefs, the patient’s val- ues 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 med- ical reasons for it. The physician remains responsible for his or her actions and gener- ally is not obligated to act in violation of
*Update of “Sterilization of Women, Including Those With Mental Disabilities” in Ethics in Obstetrics and
Gynecology, Second Edition, 2004.
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 per- forming 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 pro- vided. A variety of patient education materials are avail- able 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 limi- tations on the patient’s age and requirements for the con- sent 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 indi- viduals other than the patient, women requesting steril- ization 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 ster- ilized. 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 alter- natives. In disabled women with limited functional capa- bility, 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 menstru- al hygiene and are profoundly disturbed by their menses. On occasion, such women’s caretakers have sought hys- terectomy for these indications. Hysterectomy for the purpose of cessation of normal menses may be consid- ered only after other reasonable alternatives have been attempted.
Women may be vulnerable to various forms of coer- cion 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 men- tal 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 steriliza- tion 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 unnec- essary 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 individ- ual 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 abil- ity 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 heteroge- neous group, including those with varying degrees of pre- sumably irreversible “mental retardation” as well as those with varying types and degrees of “chronic mental ill- ness.” Some of these illnesses are reversible to varying degrees and for varying periods. The concept of “chroni- cally and variably impaired autonomy” has been pro- posed to describe such situations (3).
Physicians who perform sterilizations must be aware of widely differing federal, state, and local laws and regu- lations, 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 pre- sumptive 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 seri- ous 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 pro- vided (clarity, completeness, and lack of bias), the setting of counseling (privacy and comfort), and possible fluctu- ations 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 indi- viduals is essential. These professionals may include spe- cial 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 jurisdic- tion involved, and legal requirements for the determina- tion 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 life- saving treatment; or, as in the case of sterilization, con- senting to elective surgery).
Court approval of sterilization may be required by law or may be necessary in difficult cases because of dis- agreement among the patient’s caregivers and consul- tants. 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 determina- tion 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 non- voluntary 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 pater- nalistic 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 par- ticipate 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 interview- ing the patient, her family, caregivers, and others in her environment. If possible, alternatives (including no action) consistent with her beliefs, medical condi- tion, and social situation should be presented to deci- sion makers.
• Physicians should be aware of the possibility of undue pressure from family members whose inter- ests, 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 fam- ily members present.
• Noninvasive modalities designed to assist family members and other caregivers with setting behavioral limits should be considered as alternatives to steriliza- tion. These resources may include socialization train- ing, sexual abuse avoidance training, supportive fam- ily therapy, and sexuality education.
• Consideration should be given to the degree of cer- tainty of various adverse outcomes. For example, given the patient’s living circumstances, how likely is it that she might be sexually exploited? Given avail- able knowledge concerning her reproductive poten- tial (ovulatory status and tubal patency), how likely is it that she will become pregnant? How likely are adverse medical or social consequences from a preg- nancy? Because it is uncommon for such risks to be reliably predicted, it may be preferable to recom- mend 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.
Summary
Sterilization is an elective procedure with permanent and far-reaching consequences. Physicians who perform ster- ilization 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 care- givers 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.
References
1. Benefits and risks of sterilization. ACOG Practice Bulletin No. 46. American College of Obstetricians and Gynecolo- gists. Obstet Gynecol 2003;102:647–58.
2. Sterilization of persons in federally assisted family planning projects. 42 C.F.R. § 50 Subpart B (2006).
3. McCullough LB, Coverdale J, Bayer T, Chervenak FA. Ethically justified guidelines for family planning interven- tions to prevent pregnancy in female patients with chronic mental illness. Am J Obstet Gynecol 1992;167:19–25. 4. 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.
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Sterilization of women, including those with mental disabilities. ACOG Committee Opinion No. 371. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;110:217–20. ISSN 1074-861X