Bioethics Forum Essay
Requests for Sterilization, Abortion Bans, and Reproductive Justice
In the nearly three months since the United States Supreme Court’s Dobbs v. Jackson Women’s Health Organization decision eliminated the constitutional right to an abortion, doctors have reported increased in demand for sterilization by female patients. This interest in permanent contraception likely reflects patients’ fear of losing reproductive autonomy. It also raises several ethical issues concerning reproductive justice, including disparities in access to care and questions about autonomous decision-making.
Most of the gynecologic patients who undergo sterilization, or surgery for permanent contraception, are Black and Hispanic. This was the case even before the Dobbs decision. As communities of color are disproportionately impacted by restrictions on abortion access and have higher rates of maternal morbidity and mortality, those restrictions are not only inequitable, but also dangerous. Since gynecologic patients from marginalized backgrounds disproportionately make up patients receiving permanent contraception and are also the patients most impacted by abortion restrictions and the associated outcomes, we think it’s likely that even more Black and Hispanic patients, compared with white patients, will seek permanent contraception in response to the Dobbs decision.
Differences in preference for permanent contraception influenced by individual, familial, and cultural values and preferences should be understood, respected, and upheld. But it is unclear to what degree these differences are the result of informed consent and personal choice. The disparity may be due to external factors and barriers. Given the history of forced sterilization in the United States, especially impacting Black women, it is important to recognize the heightened threat to reproductive justice for this community. For example, clinicians’ implicit biases influence contraceptive counseling and, some evidence suggests, may lead to greater willingness to recommend permanent contraception to Black or poor women. It is imperative that clinicians consider the history of reproductive coercion among these groups and implicit biases that may further perpetuate racial disparities in permanent contraception, while also maintaining a commitment to honoring autonomy in reproductive decision-making.
Even as most requests for permanent contraception come from Black and Hispanic women, many of them face a clinically and ethically unjustifiable waiting period for the procedure, imposed by Medicaid, as we discussed in an article in the current Hastings Center Report. Black and Hispanic patients represent nearly half of women insured by Medicaid. The Medicaid policy mandates that a patient must wait at least 30 days, but no longer than 180 days, after signing a consent form to undergo a permanent contraception procedure. (It allows for a 72-hour waiting period instead in specific circumstances, such as premature delivery.) Although this policy was instituted to reduce the risk of coercion associated with sterilization, the implication that patients with Medicaid insurance, but not private insurance, need a mandated amount of time to consider the impact of their medical decision-making is deeply problematic. Autonomy issues aside, patients with Medicaid have unique barriers to attending outpatient postpartum visits and Medicaid insurance often expires postpartum, thus posing additional logistical hurdles to desired permanent contraception. In addition to the long waiting period, the Medicaid policy presents another obstacle to permanent contraception. For various reasons, the Medicaid consent form for sterilization is difficult to understand and access. For example, the form is written at a ninth-grade reading level, thus some patients with may be unable to read it and provide truly informed consent for the procedure.
The reported increase in requests for permanent contraception following the Dobbs decision brings new ethical wrinkles. When a patient’s decision to seek permanent contraception is influenced by legal restrictions in accessing care—bans or limits on abortion— how can the decision be truly autonomous? How should clinicians counsel patients who request permanent contraception and perform the surgeries when a patient’s choice may reflect coercion from state laws banning abortion–and potentially increase the risk of the patient’s regret if these laws are repealed? The patient populations that the Medicaid consent form and waiting period policies were established to protect—Black and Hispanic women–are also those most affected by these barriers preventing individuals from achieving true reproductive autonomy. Regardless of the surrounding ethical and legal challenges, the role of clinicians must be to educate, empower, and trust patients to make decisions that are right for them, including the decision for permanent contraception. Thus, high-quality shared decision-making between a patient and clinician is imperative to ensuring the principles of reproductive justice and contraceptive autonomy are upheld in permanent contraception counseling conversations.
Madeline Thornton (@mjthornton26) is an MD/MPH student at the University of North Carolina at Chapel Hill. Kavita Shah Arora, MD, (@KavitaShahArora) is an associate professor and the division director for general obstetrics and gynecology at the University of North Carolina at Chapel Hill and chair of the American College of Obstetrics and Gynecologists’ Committee on Ethics.
Thank you for sharing your views on the issue. The first thought that came to mind after reading the essay was the idea of therapeutic jurisprudence. Whether intentional or unintentional, the Dobbs decision has increased the “fear of losing reproductive autonomy,” reflected by the increased demand for sterilization. And as you have mentioned, marginalized groups are affected disproportionally, adding more anxiety to an already socially stressed population.
I ponder if similar worries also plague physicians, given the vague legality of what is permissible in reproductive health. In the immediate aftermath of Dobbs and the increased demand for sterilization, I also wonder if physicians were worried about the possibility of states striking down sterilization and similar procedures (Although now, after the midterm elections, this hasn’t happened and will likely never happen).
Your discussion on reproductive coercion/discrimination in the clinic and by the Medicaid system was new but sadly unsurprising. The problem of coercion in the clinic is easily addressable with enough discussion and respect for both the patient and clinician’s roles in decision-making, albeit easier said than done. As you alluded to, the complexity of Medicaid raises other ethical issues.
Regarding the waiting time before the procedure, would shortening the wait time strike a better balance between beneficence and non-maleficence? And for justice’s sake, should similar mandates be imposed on the privately insured? The complicated Medicaid process also raises questions about the roles of physicians — should they be obligated to guide patients through the Medicaid process?
Perhaps it is also an ethical issue to discuss why men shouldn’t undergo sterilization instead, given a vasectomy’s lower risks, costs (also covered by Medicaid), and potential reversibility. Why should women bear the brunt of the consequences of such legislation?
The questions you raise are also very valid: the autonomy of a decision driven by fear of legal retribution seems tenuous at best. Had the patient been in a pro-choice state, such urgency and fear would not exist; as a result, they likely would not have agreed to the procedure.
On a more hopeful note, the mid-term elections have further cemented that overturning Roe v. Wade goes against public opinion. Even in highly conservative states, referendums have moved to protect abortion rights. I hope this will mean a potential reversal of the Dobbs decision in some form and more careful consideration of the effects of jurisprudence on different groups, especially minorities.