There are unique ethical considerations when it comes to sterilization as a method of contraception because, unlike other methods, it is permanent and has far-reaching implications, according to a new Committee Opinion issued today by The American College of Obstetricians and Gynecologists (ACOG).
According to ACOG, thorough, unbiased counseling is necessary so that women considering sterilization can make a fully informed decision. When sterilization is considered for women who have limited mental capacity, the patient’s best interest should be paramount.
Sterilization is the most common method of contraception in the US. In women, both fallopian tubes are closed by tying, banding, clipping, cutting, or sealing them with electric current. This is called tubal ligation and is usually done under general anesthesia. A newer sterilization procedure uses tiny coils that are inserted into each fallopian tube that then form scar tissue that blocks the egg from meeting sperm. In men, sterilization, or vasectomy, involves clamping, cutting, and sealing the tubes that carry sperm. Vasectomy is typically performed with local anesthesia and is done in a doctor’s office or clinic.
“Sterilization is not a decision to be taken lightly because it is intended to be permanent,” according to Anne D. Lyerly, MD, chair of ACOG’s Committee on Ethics. “Women considering sterilization need comprehensive counseling on all of the reversible contraceptive alternatives. They also need to understand that while there are techniques that attempt to reverse tubal ligations, they require invasive surgery and have no guarantees of success.”
The potential of future regret with sterilization needs to be stressed to women considering it, according to ACOG. Patients also need to be informed about the estimated failure rate as well as the risk of ectopic pregnancy with sterilization. Although women do not need consent from others to undergo sterilization, they are encouraged to discuss their decision with their husband or other appropriate intimate partner because sterilization affects them as well. In many cases, it is preferable that the male partner be sterilized because it is a simpler, less invasive procedure.
Obtaining informed consent for sterilization is more difficult when it comes to women who are mentally disabled or who have a mental illness. In these cases, it is essential to obtain the assistance of professionals who are trained in communicating with mentally disabled individuals. Court approval of sterilization may be required by law in situations in which there is disagreement among the patient’s caregivers and consultants.
“Though sterilization is technically fairly straightforward, it can present serious ethical issues, especially when it comes to women with limited mental capacity,” according to Dr. Lyerly. “Physicians need to proceed with great care when they consider performing sterilization.”
If a woman has a treatable mental disorder that affects her ability to give informed consent, efforts should be made to avoid stressors and adjust medication that may allow her to exercise full autonomy. If this fails, ACOG recommends that:
Efforts be made to conform to the patient’s values and beliefs about reproduction. Interviewing the patient, her family, and caregivers can help provide this information.
The woman be interviewed without family members present, when appropriate, because there is the possibility of undue pressure from family.
Socialization training, sexual abuse avoidance training, family therapy, and sex education be considered as alternatives to sterilization.
A reversible long-term form of contraception, such as the intrauterine device (IUD), injectable progestin, or implants, be considered as they may be preferable to sterilization. In most cases, the chosen method of contraception should be the least restrictive in preserving future reproductive options.
Physicians must be familiar with relevant laws and regulations regarding sterilization, including age constraints and informed consent requirements. Those physicians who have a conscientious objection to performing sterilization are obligated, nonetheless, to refer patients to facilities that offer sterilization services.