FEU-NRMF

INSTITUTE OF MEDICINE • Contraceptive counseling and the rendering of contraceptive

Bioethics 2 care are clear examples of medical care requested for other
Polly T. Chua-Chan, M.D., MPH, MHA, FPAFP than the treatment of disease.


ETHICS IN HUMAN SEXUALITY
1) The principle of beneficence requires that contraceptive
Sexual and Reproductive Health methods must be safe, effective, and acceptable to women.
• The UN program for action (Chapter VII, para 7.2) described 2) In introducing contraceptive methods, medical practitioners
SRH as follows: must be guided by respect for an individual’s autonomy.
- Reproductive health care is defined as the constellation of 3) The same respect for autonomy requires that standards
methods, techniques and services that contribute to especially relevant to the introduction of methods of fertility
reproductive health and well-being by preventing and regulation should include both facilitating informed choice
solving reproductive health problems. and delivering quality care.
- It also includes sexual health, the purpose of which is the 4) There are 2 major aspects to delivering quality of care:
enhancement of life and personal relations, and not medical quality requirements and the need to take into
merely counseling and care related to reproduction and account the woman’s express wishes.
sexually transmitted diseases. a. Medical quality requirements include that a range of
appropriate contraceptive methods is offered, that
Introduction appropriate support counseling services are available
and that providers are technically competent.
• Health should be viewed as a human right that contributes to
b. Interpersonal relations with healthcare personnel must
social and economic development.
be respectful and take into account women’s inputs
• The good health of the individual, the family, the community
and opinions.
and the nation depends on the quality of SRH.
• Expression of sexual and reproductive activities, and equal
interpersonal relations between men and women should be Ethical Considerations in Sterilization
accepted as a normal element of life and is a human right. • Decisions about sterilization involve personal values and
therefore may be subject to inappropriate practitioner bias.
• Ethical considerations evolve from these unique and
Some people find themselves in these situations:
controversial aspects of fertility control.
o A second year medical student is in love with her boyfriend
• Sterilization differs from other contraceptive methods because
and wonders whether they ought to begin sleeping together
in theory it eliminates any further option to procreate. The
o A minister is asked to counsel a husband and wife, one of
intention of permanency underscores the need for patients and
whom is involved in an affair.
practitioners to consider a special set of ethical issues and the
well-documented possibility of later regret by the patient.
What do all these people have in common? • The obvious relationship of sterilization to procreation, the
o Need to make decisions that involve sexuality, and they find potential irreversibility of the procedure, and its usually elective
that issues of values make the decisions difficult. nature require that certain ethical considerations receive
o The two principal conceptual frameworks for dealing with special emphasis.
questions of values are religion and philosophy, both of • Although these considerations involve matters of private and
which consider ethics. individual choice, they may also have societal implications.

Ethical Aspects of Human Sexuality Special Ethical Considerations in Sterilization
• Two reasons: 1. Because a patient’s ability to procreate may significantly affect
1) The scientific goal of explaining sexual phenomena must the lives of others, the practitioner should encourage the
take religious beliefs and ethical concerns into account. patient to include other appropriate persons including her
- They are important influences on people’s behaviors, partner in the counseling process. However, the partner’s
especially in matters of sex, so we cannot fully consent must not be obligatory.
understand why people do what they do without 2. The withholding of other medical care by linking it to the
considering these influences (Regnerus, 2007). patient’s agreement to undergo sterilization is coercive and
2) There is the personal importance of ethics. unacceptable.
• One pregnancy after another. Is there a need for 3. The physician’s personal values or sense of societal objectives
contraception? Family planning? Or a newer term they call, should never be a basis for urging sterilization. Ethnic, racial or
responsible parenthood? socioeconomic factors should never be grounds for limiting a
patient’s choices about sterilization.
Contraception 4. The physician’s personal values should not limit counseling,
• Women have the right to make a choice on whether or not to services or referral.
reproduce and should therefore have access to legal, safe, 5. The rights of mentally handicapped and other vulnerable
effective and affordable methods of contraception. persons, whether institutionalized or not, should be carefully
• Responsible control of procreation enjoys wide social protected. Even if a person is unable to make their own decision
acceptance. because of mental incapacity or mental retardation,
• However, none of the current methods of fertility control fully nevertheless they must be involved in the decision-making
satisfies the ideal of safety, effectiveness, reversibility, ease and process to the fullest extent their capacity allows, and their best
religious acceptance. interests must be taken into account.

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6. Hysterectomy solely for the purpose of sterilization is Where abortion law is restrictive and a heavy burden of unsafe
inappropriate because of the disproportionate risks and costs. abortion is evident, practitioners and associations should urge
7. Special informed consent considerations inherent in wider legal access to services.
sterilization counseling include: • Legal or social coercion about the type or timing of family
a) Sterilization is intended to be permanent; planning should be avoided as this violates ethical principles as
b) Life circumstances may change; well as human rights. Obstetricians and gynecologists should
c) The patient may later regret her sterility; act as advocates for appropriate and safe methods of family
d) Male sterilization may be an appropriate alternative; planning.
e) There is a measurable failure rate with any sterilization • Males should share the responsibility in family planning, but it
procedure. should be noted that in reproductive health there is a heavy
8. No minimum or maximum number of children may be used as burden on women. The importance of male participation and
criteria for access to sterilization. responsibility in the protection of women has become much
9. At a public policy level, the profession has a duty to be a voice greater with the emergence of HIV/AIDS.
of reason and compassion, pointing out when legislative and • If a physician or health worker is either unable or unwilling to
regulatory measures interfere with personal choice and provide a desired method of family planning or medical service
appropriate medical care. for non-medical reasons, he or she should make every effort to
10. Practitioners may also encounter situations in which, according achieve appropriate referral.
to their best judgment, sterilization would not be appropriate. ~ Paris, October 2008
It is the right of these practitioners to abstain from the
performance of the sterilizing procedures. Ethical Aspects of the Introduction of Contraceptive Methods for
Women (FIGO)
Ethics in Family Planning (FIGO) • The principle of beneficence requires that new contraceptive
Background methods must be safe, effective, and acceptable to women.
• Family planning enables couples and individuals to decide freely • In introducing new contraceptive methods, medical
and responsibly on the number and spacing of their children, to practitioners must be guided by respect for an individual’s
have the information and means to do so, to ensure informed autonomy. This respect for autonomy is reflected in
choices, and have available a full range of safe and effective international standards of reproductive rights.
methods. • The same respect for autonomy requires that standards
• Although tremendous advances have been made in the especially relevant to the introduction of new methods of
development of safer and more effective contraceptives and in fertility regulation should both facilitate informed choice, and
the provision of affordable and accessible family planning deliver quality care.
services, millions of individuals and couples around the world • Informed choice is a process by which a woman can freely make
are still unable to plan their families as they wish. decisions about possible health interventions and places
• In some countries, there are social and economic incentives and decision making in women’s hands so that they can exercise
disincentives that affect individual decisions about child- their rights. The foundation of informed choice is information
bearing and family size, in order to lower or raise fertility. that is “accurate, unbiased, complete and comprehensible”.
• Different cultures, religions, societies and communities as well • Respect for informed choice requires that certain information
as different political and economic situations in countries have on contraceptive methods should be provided to every woman
resulted in different positions on methods of fertility considering using them, including:
regulation, and views are changing with time. Views are - Proper use
affected by the legal disposition of governments to provide fully - Contraindications
available, informed choices to couples or individuals to practice - Effectiveness in preventing pregnancy
family planning. - Continuing to protect against STI’s
• The modern revolution in contraceptive methods has provided - Possible side-effects
women with reliable methods of family planning, which they - Possible interaction with other drugs or conditions
can use independently or in cooperation with their male • Respect for women’s autonomy requires that each woman
partners. However, with many contraceptive methods, women should be explicitly informed that at any time she can decide to
have to assume the inconvenience and the risk involved. stop using the method she chooses (For example: she should be
able to have an intrauterine device or implantable contraceptive
Recommendations removed on request)
• The obstetrical and gynecological professions and other • Healthcare practitioners are ethically required to work to
relevant health workers should enable and support responsible eliminate obstacles to informed choice. To that end, among
voluntary decisions about child-bearing and use of methods of other efforts, power imbalances must be acknowledged and
family planning of individual’s choice, as well as ensure minimized. Staff must be well trained; alternative methods of
availability of methods for regulation of fertility that are not conveying information must be in place in order to respond to
against the law. Professional associations must play a pivotal women who, for instance, cannot read; staff biases and
role in ensuring the availability of contraceptive services and objections to methods of fertility regulation must not be
ongoing research in this area. conveyed to patients.
• In no case should abortion be promoted as a method of family • The duty to benefit patients requires that an important goal of
planning. Prevention of unwanted pregnancies must always be practitioners should be to offer contraceptive methods within
given the highest priority, and all attempts should be made to the context of high quality reproductive and sexual health
eliminate the need for abortion. In circumstances in which services.
abortion is not against the law, such abortion should be safe.

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 There are two major aspects to this: medical quality have not freely requested such procedures or who have not
requirements, and the need to take into account women’s previously given their free and informed consent. This is so
expressed wishes. even if such procedures are recommended as being in the
- Firstly, medical quality requirements include that a range women’s own health interests.
of appropriate contraceptive methods is offered, that • Only women themselves can give ethically valid consent to
appropriate supportive counseling services are available, their own sterilization. Family members – including husbands,
and that providers are technically competent. parents, legal guardians, medical practitioners and, for
- The second aspect requires that interpersonal relations instance, government or other public officers – cannot consent
with healthcare personnel be respectful and take into on any woman’s or girl’s behalf.
account women’s input and opinions. • Women's consent to sterilization should not be made a
~ Ljubljana, 1996 condition of access to medical care – such as HIV/AIDS
treatment, natural or cesarean delivery, or abortion – or of any
Female Contraceptive Sterilization (FIGO) benefit such as medical insurance, social assistance,
Background employment, or release from an institution. In addition,
• Human rights include the right of individuals to control and consent to sterilization should not be requested when women
decide on matters of their own sexuality and reproductive may be vulnerable, such as when requesting termination of
health, free from coercion, discrimination, and violence. This pregnancy, going into labor, or in the aftermath of delivery.
includes the right to decide whether and when to have children, • Further, it is unethical for medical practitioners to perform
and the means to exercise this right. sterilization procedures within a government program or
• Surgical sterilization is a widely used method of contraception. strategy that does not include voluntary consent to
An ethical requirement is that performance be preceded by the sterilization.
patient's informed and freely given consent, obtained in • Sterilization for prevention of future pregnancy cannot be
compliance with the Guidelines Regarding Informed Consent ethically justified on grounds of medical emergency. Even if a
(2007) and on Confidentiality (2005). future pregnancy may endanger a woman's life or health, she
- Information for consent includes, for instance that: will not become pregnant immediately, and therefore must be
a. Sterilization should be considered irreversible; given the time and support she needs to consider her choice.
b. Alternatives exist such as reversible forms of family Her informed decision must be respected, even if it is
planning; considered liable to be harmful to her health.
c. Life circumstances may change, causing a person later • As for all non-emergency medical procedures, women should
to regret consenting to sterilization; be adequately informed of the risks and benefits of any
d. Procedures have a very low but significant failure proposed procedure and of its alternatives. It must be
rate. explained that sterilization must be considered a permanent,
• Methods of sterilization generally include tubal ligation or other irreversible procedure that prevents future pregnancy and that
methods of tubal occlusion. Hysterectomy is inappropriate non-permanent alternative treatments exist. It must also be
solely for sterilization because of disproportionate risks and emphasized that sterilization does not provide protection from
costs. sexually transmitted infections. Women must be advised about
• Once an informed choice has been freely made, barriers to and offered follow-up examinations and care after any
surgical sterilization should be minimized. procedure they accept.
- In particular: • All information must be provided in language, both spoken
a) Sterilization should be made available to any person and written, that the women understand, and in an accessible
of adult age; format such as sign language, Braille, and plain non-technical
b) No minimum or maximum number of children may be language appropriate to the individual woman's needs. The
used as a criterion for access; physician performing sterilization has the responsibility of
c) A partner's consent must not be required, although ensuring that the patient has been properly counseled
patients should be encouraged to include their regarding the risks and benefits of the procedure and its
partners in counseling; and alternatives.
d) Physicians whose beliefs oppose participation in • The UN Convention on the Rights of Persons with Disabilities
sterilization should comply with the Ethical includes recognition “that women and girls with disabilities are
Guidelines on Conscientious Objection (2005). often at greater risk of violence, injury or abuse, neglect or
• Evidence exists, including by governmental admission and negligent treatment, maltreatment or exploitation.”
apology, of a long history of forced and otherwise non- Accordingly, Article 23(1) imposes the duty “to eliminate
consensual sterilization of women, including Roma women in discrimination against persons with disabilities in all matters
Europe and women with disabilities. Reports have documented relating to marriage, family, parenthood and relationships, on
the coerced sterilization of women living with HIV/AIDS in an equal basis with others, so as to ensure that:
Africa and Latin America. Fears remain that ethnic and racial a) The right of all persons with disabilities who are of
minority, HIV-positive, low-income, and drug-using women; marriageable age to marry and to found a family is
women with disabilities; and other vulnerable women around recognized;
the world are still being sterilized without their own freely b) The rights to decide freely and responsibly on the
given, adequately informed consent. number and spacing of their children are recognized;
• Medical practitioners must recognize that, under human rights c) The means necessary to enable them to exercise
provisions and their own professional codes of conduct, it is these rights are provided;
unethical and in violation of human rights for them to perform
procedures for prevention of future pregnancy on women who

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 d) Persons with disabilities, including children, retain Sexual Rights
their fertility on an equal basis with others.” • The World Association of Sexology and the World Health
Organization (WHO, 2006) identified a number of sexual rights
Recommendations for all people.
• No woman may be sterilized without her own previously given 1) The right to sexual freedom.
informed consent, with no coercion, pressure, or undue - Sexual freedom encompasses the possibility for
inducement by healthcare providers or institutions. individuals to express their full potential. This
excludes all forms of sexual coercion, exploitation,
• Women considering sterilization must be given information of and abuse at any time and situations in life.
their options in the language in which they communicate and 2) The right to sexual autonomy, sexual integrity, and safety
understand, through translation if necessary, in an accessible of the body.
format and plain non-technical language appropriate to the - This right involves the ability to make autonomous
individual woman's needs. Women should also be provided decisions about one’s sexual life within a context of
with information on non-permanent options for one’s own personal and social ethics. It also
contraception. Misconceptions about prevention of sexually encompasses control and enjoyment of our own
transmitted diseases (STDs), including HIV, by sterilization need bodies free from torture, mutilation, and violence of
to be addressed with appropriate counseling about STDs. any sort.
3) The right to sexual privacy.
• Sterilization for prevention of future pregnancy is not an - This involves the right for individual decisions and
emergency procedure. It does not justify departure from the behaviors about intimacy as long as they do not
general principles of free and informed consent. Therefore, the intrude on the sexual rights of others.
needs of each woman must be accommodated, including being 4) The right to sexual equality.
given the time and support she needs – while not under - This refers to freedom from all forms of
pressure, in pain, or dependent on medical care – to consider discrimination regardless of sex, gender, sexual
the explanation she has received of what permanent orientation, age, race, social class, religion, or
sterilization entails and to make her choice known. physical and emotional disability.
5) The right to sexual pleasure.
• Consent to sterilization must not be made a condition of - Sexual pleasure, including autoeroticism, is a source
receipt of any other medical care – such as HIV/AIDS of physical, psychological, intellectual, and spiritual
treatment, assistance in natural or cesarean delivery, or well-being.
medical termination of pregnancy – or of any benefit such as 6) The right to emotional sexual expression.
employment, release from an institution, public or private - Sexual expression is more than erotic pleasure or
medical insurance, or social assistance. sexual acts. Individuals have a right to express their
sexuality through communication, touch, emotional
• Forced sterilization constitutes an act of violence, whether expression, and love.
committed by individual practitioners or under institutional or 7) The right to sexually associate freely.
governmental policies. Healthcare providers have an ethical - This means the possibility to marry or not, to divorce,
response in accordance with the guideline on Violence Against and to establish other types of responsible sexual
Women (2007). associations.
8) The right to make free and responsible reproductive
• It is ethically inappropriate for healthcare providers to initiate choices.
judicial proceedings for sterilization of their patients, or to be - This encompasses the right to decide whether to have
witnesses in such proceedings inconsistently with Article 23(1) children, the number and spacing of children, and the
of the Convention on the Rights of Persons with Disabilities. right to full access to the means of regulating their
own fertility.
• At a public policy level, the medical profession has a duty to be 9) The right to sexual information based on scientific
a voice of reason and compassion, pointing out when inquiry.
legislative, regulatory, or legal measures interfere with - This right implies that sexual information should be
personal choice and appropriate medical care. generated through the process of unencumbered and
~ Goa, March 2011 yet scientifically ethical inquiry, and disseminated in
appropriate ways at all societal levels.
10) The right to comprehensive sexuality education.
- This is a lifelong process from birth through the entire
life cycle and should involve all social institutions.
11) The right to sexual health care.
- Sexual health care should be available for prevention
and treatment of all sexual concerns, problems, and
disorders.

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