Ethical and Legal Considerations for Sterilization Refusal in Nulliparous Women.

We address the ethical and legal considerations for elective tubal sterilization in young, nulliparous women in Canada, with comparison with the United States and the United Kingdom. Professional guidelines recommend that age and parity should not be obstacles for receiving elective permanent contraception; however, many physicians hesitate to provide this procedure to young women because of the permanence of the procedure and the speculative possibility of regret. At the practice level, this means that there are barriers for young women to access elective sterilization; they are questioned or not taken seriously, or their desire for sterilization is more generally belittled by health care professionals. This article argues for further consideration of these requests and considers the ethical and legal issues that arise when preventing regret is prioritized over autonomy in medical practice. In Canada, there is a paucity of professional guidelines and articles offering practical considerations for handling such requests. Compared with the U.S. and U.K. policy contexts, we propose a patient-centered approach for practice to address requests for tubal sterilization that prioritizes informed consent and respect for patient autonomy. We ultimately aim to assure physicians that when the conditions of informed consent are met and documented, they practice within the limits of the law and in line with best ethical practice by respecting their patients' choice of contraceptive interventions and by ensuring their access to care.

Obstetrician-Gynecologists' Practices in Postpartum Sterilization Without a Valid Medicaid Consent Form.

OBJECTIVE: To explore the practices of obstetrician-gynecologists (ob-gyns) in the United States surrounding postpartum sterilization when the Medicaid consent form was not valid. METHODS: Using the American College of Obstetricians and Gynecologists' online directory, we conducted a qualitative study where we recruited ob-gyns practicing in 10 geographically diverse U.S. states for a qualitative study using semi-structured interviews conducted by telephone. We analyzed interview transcripts using the constant comparative method and principles of grounded theory. RESULTS: Thirty ob-gyns (63% women, 77% nonsubspecialized, and 53% academic setting) were interviewed. Although most physicians stated that they did not perform sterilizations without a valid Medicaid sterilization form, others noted that they sometimes did due to a sense of ethical obligation toward their patient's health, being in a role with more authority or seniority, interpreting the emergency justification section of the form more broadly, or backdating the form. The physicians who said that they never went ahead without a signed form tended to work at large institutions and were concerned with losing funding and engaging in potentially illegal or fraudulent behavior. CONCLUSION: Physicians' varied behaviors related to providing postpartum sterilization without a valid Medicaid consent form demonstrate that the policy is in need of revision. Unclear terminology and ramifications of the Medicaid sterilization policy need to be addressed to ensure equitable care.

Access to Postpartum Sterilization: ACOG Committee Opinion, Number 827.

ABSTRACT: Sterilization is one of the most effective and popular forms of contraception in the United States, relied upon by 18.6% of women aged 15-49 years using contraception. Nearly half of procedures are performed during the postpartum period, yet many women who desire postpartum sterilization do not actually undergo the procedure. Factors that may decrease the likelihood of a patient obtaining desired postpartum sterilization include patient-related factors, physician-related factors, lack of available operating rooms and anesthesia, federal consent requirements, and receiving care in some religiously affiliated hospitals. In all discussions and counseling regarding contraception, including postpartum sterilization, it is important to engage in shared decision making while supporting personal agency and patient autonomy. Equitable access to postpartum sterilization is an important strategy to ensure patient-centered care while supporting reproductive autonomy and justice when it comes to decisions regarding family formation. This revision includes updates on barriers to postpartum sterilization and guidance for contraceptive counseling and shared decision making.

COVID-19 highlights the policy barriers and complexities of postpartum sterilization.

Multiple barriers exist to sterilization in the postpartum period. One such barrier, the Medicaid Title XIX sterilization policy, requires publicly insured patients to complete a sterilization consent form at least 30 days prior to their scheduled procedure. While this policy was set in place in the 1970s to address the practice of coerced sterilization among marginalized women, it has served as a significant barrier to obtaining the procedure in the contemporary period. The COVID-19 pandemic has highlighted specific complexities surrounding postpartum sterilization and created additional barriers for women desiring this contraceptive method. Despite the time constraints to perform postpartum sterilization, some hospital administrators, elective officials, and state Medicaid offices deemed sterilization as "elective." Additionally, as the Center for Medicare and Medicaid Services (CMS) has revised telemedicine reimbursement and encouraged its increased use, it has provided no guidance for the sterilization consent form, use of oral consents, and change to the sterilization consent form expiration date. This leaves individual states to create policies and recommended procedures that may not be accepted or recognized by CMS. These barriers put significant strain on patients attempting to obtain postpartum sterilization, specifically for patients with lower incomes and women of color. CMS can support reproductive health for vulnerable populations by providing clear guidance to state Medicaid offices, extending the 180-day expiration of a sterilization consent form signed prior to the pandemic, and allowing for telemedicine oral consents with witnesses or electronic signatures.

The Degenerating Sex: Female Sterilisation, Medical Authority and Racial Purity in Catholic Brazil.

This article examines female sterilisation practices in early twentieth-century Rio de Janeiro, Brazil. It argues that the medical profession, particularly obstetricians and psychiatrists, used debates over the issue to solidify its moral and political standing during two political moments of Brazilian history: when the Brazilian government separated church and state in the 1890s and when Getúlio Vargas's authoritarian regime of the late 1930s renewed alliances with the Catholic church. Shifting notions of gender, race, and heredity further shaped these debates. In the late nineteenth century, a unified medical profession believed that female sterilisation caused psychiatric degeneration in women. By the 1930s, however, the arrival of eugenics caused a divergence amongst physicians. Psychiatrists began supporting eugenic sterilisation to prevent degeneration - both psychiatric and racial. Obstetricians, while arguing that sterilisation no longer caused mental disturbances in women, rejected it as a eugenic practice in regard to race. For obstetricians, the separation of sex from motherhood was more dangerous than any racial 'impurities', both phenotypical and psychiatric. At the same time, a revitalised Brazilian Catholic church rejected eugenics and sterilisation point blank, and its renewed ties with the Vargas regime blocked the medical implementation of any eugenic sterilisation laws. Brazilian women, nonetheless, continued to access the procedure, regardless of the surrounding legal and medical proscriptions.

A regulamen do procedimento de esterilazacao valuntaria no Brasil e na Espanha / La regulación del procedimiento de esterilización voluntaria en Brasil y España / The regulation of voluntary sterilization procedure in Brazil and Spain / La regulació del procediment d'esterilització voluntària al Brasil i Espanya

A saúde sexual e reprodutiva é um direito humano fundamental que se concretiza através dos Direitos Sexuais e Reprodutivos, e a esterilização voluntária é um método contraceptivo importante para a promoção do exercício desses direitos. Enquanto no Brasil, o legislador optou pela imposição de limites para sua realização, na Espanha, o regramento promoveu a igualdade entre as pessoas, respeitando a autodeterminação corporal, especialmente das mulheres. A partir desse panorama, pretende-se identificar e compreender quais fundamentos justificam (ou não) a imposição de limites para o acesso ao procedimento. Para esse fim, utilizar-se-ão as contribuições jus-filosóficas dos autores Ronald Dworkin e Jürgen Habermas, traçando um paralelo com o regramento espanhol sobre o tema

La salud sexual y reproductiva es un derecho humano fundamental que se concreta a través de los derechos sexuales y reproductivos, y la esterilización voluntaria es un método anticonceptivo importante para promover el ejercicio de estos derechos. Mientras que en Brasil el legislador optó por la imposición de límites para su realización, en España la norma promovió la igualdad entre las personas, respetando la autodeterminación del cuerpo, especialmente de las mujeres. A partir de este panorama, pretendemos identificar y comprender qué fundamentos justifican (o no) la imposición de límites para el acceso al procedimiento. Con este fin, se utilizarán las contribuciones jus-filosóficas de los autores Ronald Dworkin y Jürgen Habermas, trazando un paralelismo con la norma española sobre el tema

Sexual and reproductive health is a fundamental human right concretized through sexual and reproductive rights, whose exercise is also promoted by voluntary sterilization. In Brazil, while the lawmaker opted for the imposition of limits for the realization of this contraceptive method, in Spain, the law promoted equality among people, respecting body self-determination, especially of women. From this panorama, we intend to identify and understand which fundamentals justify (or not) the imposition of limits to access this procedure. Therefor, the jus-philosophical contributions of the authors Ronald Dworkin and Jürgen Habermas will be used, tracing a parallel with the Spanish law across this subject

La salut sexual i reproductiva és un dret humà fonamental que es concreta a través dels drets sexuals i reproductius, i l'esterilització voluntària és un mètode anticonceptiu important per a promoure l'exercici d'aquests drets. Mentre que al Brasil el legislador va optar per la imposició de límits per a la seva realització, a Espanya la norma va promoure la igualtat entre les persones, respectant l'autodeterminació del cos, especialment de les dones. A partir d'aquest panorama, pretenem identificar i comprendre quins fonaments justifiquen (o no) la imposició de límits per a l'accés al procediment. A aquest efecte, s'utilitzaran les contribucions jus-filosòfiques dels autors Ronald Dworkin i Jürgen Habermas, traçant un paral·lelisme amb la norma espanyola sobre el tema

A Prospective Study on the Effects of Medicaid Regulation and Other Barriers to Obtaining Postpartum Sterilization.

INTRODUCTION: This study aimed to assess unfulfilled sterilization requests, specifically regarding issues with the Medicaid consent for sterilization, and determine the proportion of women who subsequently received interval sterilization by 3 months postpartum. METHODS: The authors conducted a prospective observational cohort study of women who gave birth over an 8-month period and requested immediate postpartum sterilization. Records of women with unfulfilled requests were reviewed up to 3 months postpartum to determine rates of postpartum follow-up and interval sterilization. Primary analysis examined unfulfilled sterilization requests associated with the Medicaid consent form and, secondarily, all other reasons for unfulfilled requests, as well as alternative contraceptive methods chosen. RESULTS: Of the 334 women who requested immediate postpartum sterilization, 173 (52%) received the requested sterilization and 161 (48%) did not. Among those whose request was unfulfilled, 91 (56.5%) still wanted the procedure, and of those women, more than two-thirds were unable to receive it because of Medicaid consent issues. Within this group, only 6 received interval sterilization by 3 months postpartum; more than one-third received a form of long-acting reversible contraception, and 24.6% did not receive postpartum care. DISCUSSION: A sizable proportion of women requesting postpartum sterilization have unfulfilled requests because of an issue with the Medicaid consent and also have a low likelihood of receiving interval sterilization by 3 months postpartum. The Medicaid consent may create barriers for women requesting postpartum sterilization, the vast majority of whom face subsequent barriers obtaining interval sterilization, thereby increasing the risk for unintended pregnancy in an at-risk population. This has important implications for reproductive justice efforts to protect vulnerable populations while minimizing barriers to desired care.

Sterilization of those with intellectual disability: Evolution from non-consensual interventions to strict safeguards.

Non-consensual sterilization is one of the characteristic historical abuses that took place mainly in the first half of the 20th century. People with intellectual disability (ID) were a prime target as part of the ideology of negative eugenics. In certain jurisdictions, laws were in force for several decades that permitted sterilization without the need for consent or with consent from third parties. The long-term adverse effects on those sterilized against their will have only more recently been recognized. In the latter half of the 20th century, human rights treaties were introduced and developed; they have, in the main, curbed sterilization abuses. Courts have developed more stringent criteria for making decisions on applications for sterilization, and nowadays there are mostly adequate safeguards in place to protect those with ID from non-consensual sterilization. The only exception should be the particular case in which, all medical and social factors having been taken into account, sterilization is overwhelmingly thought to be the right decision for the individual unable to give consent.

Deviancy, Dependency, and Disability: the Forgotten History of Eugenics and Mass Incarceration.

Three widely discussed explanations of the punitive carceral state are racism, harsh drug laws, and prosecutorial overreach. These three narratives, however, only partially explain how our correctional system expanded to its current overcrowded state. Neglected in our discussion of mass incarceration is our largely forgotten history of the long-term, wholesale institutionalization of the disabled. This form of mass detention, motivated by a continuing application of eugenics and persistent class-based discrimination, is an important part of our history of imprisonment, one that has shaped key contours of our current supersized correctional system. Only by fully exploring this forgotten narrative of long-term detention and isolation will policy makers be able to understand, diagnose, and solve the crisis of mass incarceration.

Obtaining informed consent for a sterilisation in the light of recent case law.

The need to obtain informed consent prior to any sterilisation is a very well-established ethical and legal obligation. South African law, however, does not specifically state who is responsible for obtaining informed consent before performing a sterilisation. This has implications for the liability of a surgeon or gynaecologist in circumstances where the informed consent is defective. Due to the vagueness of the applicable law, a surgeon or gynaecologist might be held liable, even in situations where he/she did not obtain the consent and relied on a nurse or assistant to procure the relevant informed consent. This article explores the relevant statutory law and canvasses two legal cases that came before the court regarding defective informed consent and the resultant liability for damages. We also make recommendations for proposed amendments to the current law to provide further clarity.

Ethical Controversy About Hysterectomy for a Minor.

One of the most complicated ethical issues that arises in children's hospitals today is the issue of whether it is ever permissible to perform a procedure for a minor that will result in permanent sterilization. In most cases, the answer is no. The availability of good, safe, long-acting contraception allows surgical options to be postponed when the primary goal of such surgical options is to prevent pregnancy. But what if a minor has congenital urogenital anomalies or other medical conditions for which the best treatment is a hysterectomy? In those cases, the primary goal of therapy is not to prevent pregnancy. Instead, sterility is an unfortunate side effect of a medically indicated treatment. Should that side effect preclude the provision of a therapy that is otherwise medically appropriate? We present a case that raises these issues, and asked experts in law, bioethics, community advocacy, and gynecology to respond. They discuss whether the best option is to proceed with the surgery or to cautiously delay making a decision to give the teenager more time to carefully consider all of the options.

Transgender Sterilisation Requirements in Europe.

The possibility of individuals procreating post-transition has long stalked debates on transgender rights. In 1972, Sweden became the first European jurisdiction to formally acknowledge preferred gender. Under the original Swedish law, applicants for gender recognition were explicitly required to prove an incapacity to reproduce-either through natural infertility or through a positive act of sterilisation. Across the Council of Europe, 20 countries continue to enforce a sterilisation requirement. When considering reforms to their current gender recognition rules as recently as 2015, the Polish executive and the Finnish legislature both rejected proposals to remove mandatory infertility provisions. This article critiques the rationales for transgender sterilisation in Europe. It places transgender reproduction, and non-traditional procreation, in the wider context of European equality and family law. Adopting a highly inter-disciplinary framework, the article explores legal, social, medical, and moral arguments in favour of sterilisation, and exposes the weak intellectual and evidential basis for the current national laws. The article ultimately proposes a new departure for Europe's attitude towards transgender parenting, and argues that sterilisation should not be a pre-condition for legal recognition.

Legal liability for failure to prevent pregnancy (wrongful pregnancy).

Can the conception of a child ever constitute damage recoverable in law? This article considers the liability of healthcare practitioners for failing to prevent a pregnancy. Developments leading to the recognition of wrongful pregnancy as a cause of (legal) action in South Africa (SA), are briefly outlined. The salient points of the relevant judgments by SA courts are set out to expose the rationale underlying the judgments and to highlight that recognition of liability for wrongful pregnancy resulted from an application of fair and equitable principles of general application. Conduct that could expose practitioners to liability is identified from reported cases and inferred from general principles laid down in case law.

Medicolegal Review: Essure Lawsuits and Legal Strategies Adverse to Gynecologists.

The minimally invasive Essure procedure for hysteroscopic sterilization is an ongoing target for litigation. Although efficacious, this device has been scrutinized by the US Food and Drug Administration (FDA) owing to alleged complications. Patients affected by these potential complications are filing lawsuits against Bayer, the manufacturer of Essure. Many of these lawsuits have been barred by preemption, a legal doctrine that limits what can be required of a product by state lawsuits once the FDA approves it; however, in the lawsuits that have been allowed to proceed, the manufacturer has used a legal strategy termed the "learned intermediary doctrine" in an effort to shift blame to the gynecologist to absolve itself of liability. The learned intermediary only requires that a manufacturer inform the gynecologist of the risks associated with the device, and the gynecologist, in turn, must notify the patients through adequate informed consent. To incorporate the necessary components of informed consent, a gynecologist should include what a reasonable practitioner would consider pertinent to the discussion, as well as what a prudent patient would want to know to make a treatment decision. This disclosure entails explaining the risks, benefits, and alternatives, which should be clearly documented in the medical records. Understanding the importance of proper documentation and the legal strategies used in suits will help gynecologists lessen liability exposure when using a medical device, such as Essure, that is being targeted for litigation.

An Evil Hitherto Unchecked: Eugenics and the 1917 Ontario Royal Commission on the Care and Control of the Mentally Defective and Feeble-Minded.

In 1917, the Ontario government appointed the Royal Commission on the Care and Control of the Mentally Defective and Feeble-Minded, headed by Justice Frank Hodgins. Its final report made wide-ranging recommendations regarding the segregation of feeble-minded individuals, restrictions on marriage, the improvement of psychiatric facilities, and the reform of the court system, all matters of great concern to the eugenics movement. At the same time, however, it refrained from using explicitly eugenic vocabulary and ignored the question of sterilization. This article explores the role the commission played in the trajectory of eugenics in Ontario (including the province's failure to pass sterilization legislation) and considers why its recommendations were disregarded.

[The Incidence of Biomedical Advances in Women. Some Reflections on the Spanish Legislation]. / La Incidencia de los Avances Biomédicos en la Mujer. Algunas Reflexiones Sobre la Normativa Española.

This article will examine how and to what extent advances in biomedical sciences have played a role in transforming the status of women. It will highlight the positive aspects of these transformations but it will also examine the issues which are currently debated and which, in my opinion, require calm and considered reflection.