Sterilisation of young, competent, and childless adults
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《英国医生杂志》
1 Medical Ethics Unit, Department of Primary Care and Social Medicine, Imperial College London, London W6 8RP, 2 Department of Maternal/Fetal Medicine, Chelsea and Westminster Hospital, London SW10 9NH
Correspondence to: P Benn p.benn@imperial.ac.uk
Is it ethical to sterilise a young woman who is determined she never wants children, even if there are no strong medical reasons to avoid pregnancy?
Case history
The General Medical Council has set out the duties of a doctor.1 They include making the care of the patient the doctor's first concern, listening to patients and respecting their views, and making sure that the doctor's personal beliefs do not prejudice a patient's care. The primary principle of the Hippocratic tradition is to "above all, do no harm." Until recently, most surgery was performed to remove diseased tissue and restore the body to reasonable physical function. The modern surgical remit has, however, expanded, and patients may request operations for other reasons. An example of this is sterilisation. Surgery is increasingly seen as a tool for enhancing a patient's life and not just preserving it.
This raises important issues, the most complex of which is the judgment between the patient's view of a life enhancing surgical procedure and the Hippocratic requirement to do no harm. Although it is clearly within doctors' competence to advise on the most appropriate treatment for the amelioration of disease, it is less clear why they are competent to determine the reasonableness of personal, life enhancing, choices made by their patients. Inevitably occasions will arise when a doctor believes that what is being requested will do more harm than good. In such cases, are doctors justified in declining a treatment and imposing their judgment on another, autonomous person? More specifically, can a doctor refuse to perform a sterilisation on a patient because he or she thinks it is the wrong choice?
Yes or no: who should choose?
Intuitively, the sterilisation of someone in their teens seems more contentious than sterilisation of someone who is 40, but it could be argued that it is strange to raise ethical concerns even about this. After all, young people are allowed to take all kinds of risks they might later regret—say in relationships, lifestyle, or financial investments. Treating people as rational adults means letting them do things they may bitterly regret later. This applies as much to young competent adults as to older ones. If our patient, at the age of 26, can lawfully damage her health by, for instance, drinking a bottle of whisky every day, it might be reasonable to ask what is so special about voluntary sterilisation.
The main question to be discussed is whether the possibility that the patient will later regret the decision to be sterilised should be taken into account when deciding whether to offer the procedure. Although sterilisation can sometimes be reversed, the chances of success are low (below 50%), and patients seeking the operation are advised to assume that it is irreversible.
An initial response to this concern is that it is unjustified, not to say condescending, to assume that the operation is likely to be regretted. People who want this operation have usually thought about it long and hard; why then not believe them when they say they are sure they will not regret it? At the same time, many people do later regret making such irreversible decisions, and it is these cases that are ethically more interesting. Studies have shown that about a fifth of women regret their decision to be sterilised.2 Furthermore, if the decision was taken when the woman was aged 18 to 24 she was four times more likely to request reversal than if she was over 30.3 Regret is also associated with failure of a relationship, but in the under 30 age group the fundamental variable seems to be age at sterilisation.4
Suppose a doctor has good evidence based reasons to believe that a particular patient will regret sterilisation 10 years later if the operation goes ahead. How should the doctor act? It is tempting to see this as a question about paternalism, about over-riding a patient's wishes for the sake of her best interests. Here, the idea is that it is not in a patient's best interests to be sterilised. In view of this, the doctor must decide how to balance the patient's present wishes and her best interests.
Present and future interests
Case The case described at the beginning of the article gives rise to three main considerations:
Doctors should not be forced to perform a sterilisation if they believe that it is not in the best interests of the patient.
To make the judgment that sterilisation is not in the patient's best interests, doctors:
Must be honest about their philosophical position. If the doctor is opposed to sterilisation in any circumstance then this should be explained to the patient and the patient should be referred to another doctor.
Must be able to explain why they believe the request for sterilisation is not in the patient's best interests (setting aside the possibility of regret).
If a competent adult patient voluntarily requests sterilisation they must be informed of the risks and benefits of the procedure, including the chance that he or she may regret it later.
If these conditions are followed, and if the doctor agrees to the procedure, it is morally defensible, even if the patient is young and childless.
Summary points
Young childless women are most likely to regret the decision to be sterilised
Rational considerations taken when young are not necessarily less good than those made when older
Later regret should not be a factor in a doctor's decision about whether sterilisation is in a patient's best interest
Sterilisation of young, childless adults for non-medical reasons is ethical if they are properly informed of all the risks, including regret
This article is part of an occasional series of articles, edited by Michael Parker and Julian Savulescu, analysing ethical issues that confront health professionals in daily practice
The series is edited by Michael Parker, reader in medical ethics at the Ethox Centre, University of Oxford (michael.parker@ethox.ox.ac.uk) and Julian Savulescu of the Oxford Uehiro Centre for Practical Ethics.
Contributors and sources: PB is a philosopher who works in analytical medical ethics and who is interested in rationality and paternalism. ML is a consultant obstetrician and gynaecologist with direct experience of the kind of patient request discussed. ML supplied the clinical details and shared the analysis with Piers Benn. PB will be the guarantor.
Competing interests: None declared.
General Medical Council. The duties of a doctor registered with the GMC. www.gmc-uk.org/standards/default.htm (accessed 5 April 2005).
Marcil-Gratton N. Premature recourse to tubal ligation in Quebec: some undesirable consequences? Sociol Soc 1987;19: 83-95.
Schmidt JE, Hillis SD, Marchbanks PA, Jeng G, Peterson HB. Requesting information about and obtaining reversal after tubal sterilisation: findings from the US collaborative review of sterilisation. Fertil Steril 2000;74; 892-8.
Jamieson DJ, Kaufman SC, Costello C, Hillis SD, Marchbanks PA, Peterson HB. A comparison of women's regret after vasectomy versus tubal sterilization. Obstet Gynecol 2002;99: 1073-9.
Lavin M. Ulysses contracts. J Appl Philosophy 1986;3; 89-101.
Pennings G. The validity of contracts to dispose of frozen embryos. J Med Ethics 2002;28: 295-8.(Piers Benn, lecturer in medical ethics a)
Correspondence to: P Benn p.benn@imperial.ac.uk
Is it ethical to sterilise a young woman who is determined she never wants children, even if there are no strong medical reasons to avoid pregnancy?
Case history
The General Medical Council has set out the duties of a doctor.1 They include making the care of the patient the doctor's first concern, listening to patients and respecting their views, and making sure that the doctor's personal beliefs do not prejudice a patient's care. The primary principle of the Hippocratic tradition is to "above all, do no harm." Until recently, most surgery was performed to remove diseased tissue and restore the body to reasonable physical function. The modern surgical remit has, however, expanded, and patients may request operations for other reasons. An example of this is sterilisation. Surgery is increasingly seen as a tool for enhancing a patient's life and not just preserving it.
This raises important issues, the most complex of which is the judgment between the patient's view of a life enhancing surgical procedure and the Hippocratic requirement to do no harm. Although it is clearly within doctors' competence to advise on the most appropriate treatment for the amelioration of disease, it is less clear why they are competent to determine the reasonableness of personal, life enhancing, choices made by their patients. Inevitably occasions will arise when a doctor believes that what is being requested will do more harm than good. In such cases, are doctors justified in declining a treatment and imposing their judgment on another, autonomous person? More specifically, can a doctor refuse to perform a sterilisation on a patient because he or she thinks it is the wrong choice?
Yes or no: who should choose?
Intuitively, the sterilisation of someone in their teens seems more contentious than sterilisation of someone who is 40, but it could be argued that it is strange to raise ethical concerns even about this. After all, young people are allowed to take all kinds of risks they might later regret—say in relationships, lifestyle, or financial investments. Treating people as rational adults means letting them do things they may bitterly regret later. This applies as much to young competent adults as to older ones. If our patient, at the age of 26, can lawfully damage her health by, for instance, drinking a bottle of whisky every day, it might be reasonable to ask what is so special about voluntary sterilisation.
The main question to be discussed is whether the possibility that the patient will later regret the decision to be sterilised should be taken into account when deciding whether to offer the procedure. Although sterilisation can sometimes be reversed, the chances of success are low (below 50%), and patients seeking the operation are advised to assume that it is irreversible.
An initial response to this concern is that it is unjustified, not to say condescending, to assume that the operation is likely to be regretted. People who want this operation have usually thought about it long and hard; why then not believe them when they say they are sure they will not regret it? At the same time, many people do later regret making such irreversible decisions, and it is these cases that are ethically more interesting. Studies have shown that about a fifth of women regret their decision to be sterilised.2 Furthermore, if the decision was taken when the woman was aged 18 to 24 she was four times more likely to request reversal than if she was over 30.3 Regret is also associated with failure of a relationship, but in the under 30 age group the fundamental variable seems to be age at sterilisation.4
Suppose a doctor has good evidence based reasons to believe that a particular patient will regret sterilisation 10 years later if the operation goes ahead. How should the doctor act? It is tempting to see this as a question about paternalism, about over-riding a patient's wishes for the sake of her best interests. Here, the idea is that it is not in a patient's best interests to be sterilised. In view of this, the doctor must decide how to balance the patient's present wishes and her best interests.
Present and future interests
Case The case described at the beginning of the article gives rise to three main considerations:
Doctors should not be forced to perform a sterilisation if they believe that it is not in the best interests of the patient.
To make the judgment that sterilisation is not in the patient's best interests, doctors:
Must be honest about their philosophical position. If the doctor is opposed to sterilisation in any circumstance then this should be explained to the patient and the patient should be referred to another doctor.
Must be able to explain why they believe the request for sterilisation is not in the patient's best interests (setting aside the possibility of regret).
If a competent adult patient voluntarily requests sterilisation they must be informed of the risks and benefits of the procedure, including the chance that he or she may regret it later.
If these conditions are followed, and if the doctor agrees to the procedure, it is morally defensible, even if the patient is young and childless.
Summary points
Young childless women are most likely to regret the decision to be sterilised
Rational considerations taken when young are not necessarily less good than those made when older
Later regret should not be a factor in a doctor's decision about whether sterilisation is in a patient's best interest
Sterilisation of young, childless adults for non-medical reasons is ethical if they are properly informed of all the risks, including regret
This article is part of an occasional series of articles, edited by Michael Parker and Julian Savulescu, analysing ethical issues that confront health professionals in daily practice
The series is edited by Michael Parker, reader in medical ethics at the Ethox Centre, University of Oxford (michael.parker@ethox.ox.ac.uk) and Julian Savulescu of the Oxford Uehiro Centre for Practical Ethics.
Contributors and sources: PB is a philosopher who works in analytical medical ethics and who is interested in rationality and paternalism. ML is a consultant obstetrician and gynaecologist with direct experience of the kind of patient request discussed. ML supplied the clinical details and shared the analysis with Piers Benn. PB will be the guarantor.
Competing interests: None declared.
General Medical Council. The duties of a doctor registered with the GMC. www.gmc-uk.org/standards/default.htm (accessed 5 April 2005).
Marcil-Gratton N. Premature recourse to tubal ligation in Quebec: some undesirable consequences? Sociol Soc 1987;19: 83-95.
Schmidt JE, Hillis SD, Marchbanks PA, Jeng G, Peterson HB. Requesting information about and obtaining reversal after tubal sterilisation: findings from the US collaborative review of sterilisation. Fertil Steril 2000;74; 892-8.
Jamieson DJ, Kaufman SC, Costello C, Hillis SD, Marchbanks PA, Peterson HB. A comparison of women's regret after vasectomy versus tubal sterilization. Obstet Gynecol 2002;99: 1073-9.
Lavin M. Ulysses contracts. J Appl Philosophy 1986;3; 89-101.
Pennings G. The validity of contracts to dispose of frozen embryos. J Med Ethics 2002;28: 295-8.(Piers Benn, lecturer in medical ethics a)