Legally Competent, But Too Young To Choose To Be Sterilized?

In the UK, female sterilisation is available on the NHS. However, as the NHS choices website points out:

Surgeons are more willing to perform sterilisation when women are over 30 years old and have had children.

Recent media reports about the experience of Holly Brockwell have detailed one woman’s anecdotal experience of this attitude amongst medics. Ms. Brockwell, 29, explains that she has been requesting sterilization every year since she was 26. However, despite professing a firmly held belief that she does not, has not, and never will want children, her requests have so far been refused, with doctors often telling her that she is ‘far too young to make such a drastic decision’. In this post, I shall consider whether there is an ethical justification for this sort of implicit age limit on consenting to sterilization.

To begin, it is important to clarify a few things about the nature of female sterilization. The surgery, which is normally performed under general anaesthetic (although it can be performed under local anaesthetic), involves blocking or sealing the recipient’s fallopian tubes. The procedure is over 99% effective as a method of contraception, and its effects are permanent. It is possible to undergo a procedure to reverse the effects, but the success rate of such reversals is only around 50%-60%, and it is not usually available on the NHS, costing around £4’500-£5’500 privately. Whilst there are other forms of reversible contraception whose effectiveness is comparable to sterilization, the latter may be preferable insofar as it does not involve the use of hormones that may induce adverse side-effects, it does not require a painful device to be implanted into the body, and it does not interfere with the spontaneity of sexual intercourse. The use of other forms of effective contraception involves at least one of these disadvantages.

In view of the availability of these other forms of contraception, it might be claimed that sterilization should not be made available on the NHS. Furthermore, it is well established that patients do not have a right to demand any sort of medical treatment that they might desire. However, these points are not germane to my discussion here. The fact is that the procedure is available on the NHS – the question I want to ask here is whether, once they are above the legal age of consent, the patient’s age is relevant in any other way to whether their request for sterilization should be respected. From now on, when I refer to the patient’s ‘age’ playing a role in the agent’s competence to consent to an intervention, I mean to refer to any further role that age is understood to play in assessments of competence amongst patients who are above the legal age of consent.

The first thing to acknowledge is that age is surely not an ethical barrier to consenting to undergoing sterilization per se. To see why, suppose that a 26-year old woman was diagnosed with uterine cancer, and that undergoing a hysterectomy was necessary for her survival. I presume that readers will share the intuition that the woman’s age in this case should not play any role in an assessment of her competence to consent to this intervention; indeed, doctors would be likely to recommend that she undergo the procedure, even though it would render her infertile.

In view of our reflections on this case, it seems that the reluctance to agree to a young woman’s request for sterilization is unlikely to be based on the fact that sterilization is ‘a drastic procedure’. Rather, it seems that such reluctance is likely to be based on the woman’s reasons for wanting to undergo the procedure. In the hysterectomy case, a procedure rendering the patient infertile is medically indicated; her reason to undergo the procedure is to ensure her survival. And there is no good reason to suppose that age plays a role in an agent’s ability to appreciate this reason. In contrast, when a healthy woman requests a sterilization, her reason for doing so is most likely to be that she values the ability to engage in sexual intercourse without risk of pregnancy. Not only that, but she believes that that she has stronger reasons to pursue this value than she has to use contraceptives that cause pain or discomfort but which maintain her fertility. Are there any good grounds for believing that age plays a role in an agent’s ability to appreciate and weigh these reasons?

I suggest that there are not. Clearly it can be difficult to project oneself into the future and to predict what one will value in 10 years times, since many of our values and priorities change over time. However, not all of them do – some of our values remain stable across the years. Individuals can often provide a rationale for holding those stable values, and are able to defend them from challenges. In so far as a doctor can have grounds for believing that a competent adult has a stable desire to undergo an irreversible procedure, the medical profession’s commitment to resecting patient autonomy suggests that this desire should be respected. As far as we can tell from the media reports, Ms. Brockwell seems to be a paradigm example of a young woman who has such a stable desire, based on a rationally endorsed ranking of values.

Of course, one can only be said to have such a stable value set after one has lived a certain number of years, in so far as stable values are defined in part by the length of time over which they are held. However, it seems plausible that even an 18 year old can have stable values that they have held over a long period of time, and for which they can provide a strong rationale. Moreover, it is at this time of life that adolescents begin to foreclose their abilities to pursue certain options in order to focus on pursuing ends that they themselves prefer to pursue. As such, I suggest that it is at least conceptually possible that an 18 year old could competently request sterilization on the basis of a stable desire, especially if she is makes the request in full awareness of the fact that many people’s desires change as they grow older.

Perhaps it might be argued that by refusing sterilization, doctors are safeguarding women’s autonomy, by maintaining their available options. However, whilst the availability of some options may be important from the point of view of autonomous choice, reducing one’s options can be an expression of autonomy, when having the freedom to pursue a particular end x impairs one’s freedom to purse another end y that they autonomously prefer to x. The case under consideration seems to be an example of this – the woman’s fertility impairs her freedom to engage in sexual intercourse without the risk of pregnancy, and without experiencing the adverse side-effects of other contraceptive methods.

A charitable reading of doctor’s reluctance here is to understand it as being rooted in epistemological concerns with regard to the identification of stable desires, rather than in a paternalistic desire to ensure that women prioritise fertility over what they may regard as wanton hedonism. That is, the justification for the position might be that doctors are refusing to allow sterilizations because it can be very difficult to determine that a young woman’s desire not to have children is ‘stable’, and because they believe that the potential harm of making a ‘false positive’ assessment of a young woman’s apparently stable desire to not have a child far outweighs the potential value of the increased well-being of a young woman who is correctly identified as holding such a stable desire, and who is sterilized on the basis of that assessment. Furthermore, it might be argued that it is easier to identify stable desires as a person ages, and that the harm of making a ‘false positive’ assessment in a woman who already has children is not as severe as making a false positive assessment of a woman who has no children.

I leave the reader to assess the merits (or otherwise) of this position. However, the claim that doctors are relying on this sort of justification is thrown into doubt by the fact that that the NHS choices website page on male sterilization does not suggest that surgeons would be reluctant to carry out a vasectomy on a male under a certain age, or on a man who has not had children. This is particularly puzzling in view of the fact that vasectomies are far harder to reverse than female sterilization. In view of the seeming absence of comparable reluctance to carry out male sterilization, we might justifiably worry that the justification for doctors’ reluctance to carry out voluntary non-medically indicated sterilization on young women may be more likely to rely on paternalistic attitudes, rather than on epistemological concerns regarding stable desires. There seems little reason to suppose that it is easier to identify a young man’s stable desire not to have children than it is to identify a young woman’s stable desire not to have children.