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Types of sterilisation procedures law medical essay

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Status of ethical issues in sterilisation in IndiaAkhilesh PatelPBC 2: Ethics, Legislation and Governance in Public HealthProf. Shalini Bharatshss, tiss, v. n. purav marg, mumbai 400088

Content

What is SterilisationThe Methods usedA brief History of SterilisationIssues in SterilisationEthical Issues in DetailConclusionReferences

What is Sterilisation?

Sterilisation is a procedure by which an individual male or female loses his or her ability to produce offspring. In the ancient times, as the evidences suggest, it was the procedure for animals such as Ox and Camels1. Oxen were generally castrated so that they can loss their aggressiveness and then farmers could easily use them for agriculture and other purposes. While in desert areas (Arab countries specially) use camel as the suitable mode of transport in the water deficient areas. During their long journeys, they used to put a stone in the uterus of female camels, which prevent the conception along with castration of male camels2. As we evolved and our population goes on exponential increase after industrialisation, medical techniques that intentionally lead a person unable to reproduce, were evolved broadly used as a method of birth control.

Types of Sterilisation Procedures:

The various types can be classified in many ways: On the basis of person receiving it: Male and Female; On the basis of expertise involved: Surgical and non-surgical. Surgical methods are performed by expert surgeon, usually a gynaecologist. Generally requires stay of the patient in the hospital or healthcare facility. Now a days, these procedures are considered minor and do not require stay for more than a day. While non surgical methods are generally pharmacological methods, with the help of certain drugs, sterilisation is achieved. The generally performed procedure in Females is called Tubectomy, and in Males it is called Vasectomy. Though two other medical procedures which lead to sterility are Hysterectomy in Females & Castration in males, but these methods are not used in birth control. Recently, a new method called ” Trans-luminal procedure” is also used in birth control. Certain drugs which cause permanent sterility (Pharmacological Methods) are Progesterex & Quinacrine. The later is anti malarial with many side effects. Commonly used methods which include Tubectomy & Vasectomy have some failure rate; Vasectomy 1 in 2000 & Tubectomy 1 in 200. Thus we can say that Vasectomy is much more efficient and safe way of sterilisation.

A brief history of sterilisation:

During the time of Hippocrates, Female sterilization was the recommended procedure for preventing hereditary mental diseases. James Blundell introduced surgical sterilization in 1823 for the prevention of high risk pregnancies. At the later time, Vasectomy was performed in the US at the end of the 19th century, mainly to prevent hereditary disorders.

Issues in Sterilization:

The various issues encountered can be broadly categorised into three major categories, namely Clinical Issues, Legal Issues and Ethical Issues5. Though all the three constitute the ethical issues broadly, but still clinical and legal are incorporated in the ethics of medical practice and constitutional rights respectively.

Clinical issues:

The method must be safe, simple and effective. Surgical methods are generally difficult to reverse sterilization and have a low success rate. Further pregnancy has a higher risk of ectopic pregnancies. Sterilization should thus be considered permanent. Decision should thus be made by the woman based on voluntary informed choice and should not be made under duress. Similarly the International Federation of Gynaecology and Obstetrics (FIGO) stated that, ” no incentives should be given to promote or discourage any particular decisions regarding sterilization”. Royal College of Obstetrics and Gynaecology guidelines state that women under the age of 30 (or those without children) should be counselled in case of later regret. Care should be taken in women who have recently experienced a loss in relationship, or during pregnancy

Legal issues:

Spousal consent is not required for sterilisation. Prior sanction by a high court judge should be sought in all cases of sterilisation when there is doubt over mental capacity to consent. Full consent requires that patients should be informed that reversal operations, IVF and ICSI (intra-cytoplasmic sperm injections) are rarely provided. Male sterilization as a means of genocide happened during Nazi rule in Germany. Forced sterilization which is the process of permanently ending someone’s ability to reproduce without his or her consent was seen in many countries including India. In the early 1900’s, the US had a eugenics program to perfect the gene pool. It was in 1907 that Indiana put the first law on the books broaching the subject of forced sterilization. Peru has had a target for the number of sterilizations to take place each year. In 1996, the target was 100, 000 which was not met and next year was increased to 130, 000. Also, the women were the victims of the sterilizations.

Ethical issues:

The Non-Therapeutic procedure6: first of all we should understand that sterilisation is a non therapeutic procedure which means there is no need for the individual as such, and will not cause any benefit for the recipient. This increases the liability of the family of the individual, medical doctor, society and the government. They must show obligation to that person. Informed consent7, 9: if an individual who’ll be undergoing sterilisation, must be informed of all pros and cons of not only the procedure but also the attached medical and social consequences later in his/her life. She/he should make informed choice before the informed consent. Quality of services7: Ironically, government is promoting sterilisation procedures. Mostly government hospitals are the sites. The quality of services provided there is very bad. The hospital staff is very ignorant and the doctors are too busy to even look at the patient after such procedure. Hygiene and poor sanitary conditions7: The sanitary and hygienic conditions in such government facilities are very poor. Usually the tap and the flush do not outflow water and thus the scenario looks very bad. No daily cleanliness of the floor, poor waste segregation and accumulation of such waste in the corners make the situation worst. Pressure of targets7, 10: Though government never accept the questions of targets, but many doctors and public health workers in their press interviews mentioned that they’re given some targets and too fulfil that target they do everything to save their jobs or promotions or extra earnings. Death of Children after sterilisation7: as mentioned earlier that the surgical sterilisation procedures are irreversible and also even if reversed there are very less chances that the man or woman be fertile. Here arise another question that what about that couple who lost all their children in some mishap? Will they be able to conceive later on? Incentives8: In some of the news papers, reported that during mass sterilisation camps, incentives in the various forms from Monetary to Electronic and other goods. Various Human Rights agencies, FIGO are against off any form of incentive for any such procedure. UP, Bihar, Rajasthan, Tamilnadu & MP giving cash incentives for women and motivators are announced to create a competitive environment by encouraging men and women to volunteer for sterilization, and in return are offering a cars, DVDs, TVs, Sarees, mobile phones, Licenses for shops, water connections, plot of land. Mentally challenged and minors11? Means of getting a government certificate or a means to save their jobs? Motivators do not fully inform the women about procedure of sterilization operation or its the side effects. Operation procedure conducted without operation equipment around, Mandatory tests before the sterilization not done before the operation is conducted. Lack of information about complications & side effects12: Generally it’s been observed that the person undergoing such procedure is not well informed of the complications and side effects. There are evidences of deaths following sterilisation, not only in women but in case of men too. Lack of options available12: though there are many methods of birth control some of them are very popular though. But they all are temporary methods of sterilisation, and in the country like india where emphasis is given on sterilisation, not other methods are available which be effective, easy and reversible. Camp scenario13: Government organises many sterilisation camps to reach the people in grass root levels. Tents are used generally for roof, and no adequate privacy care is taken though most of the women undergo sterilisations in such camps. Evidences are that the women are handled like a gunny bag in the unconscious state and thrown on and off the table like gunny bag. Priority of government Vs needs and preferences of women13: For example, those couples with more two or more than two children are given no choice other than sterilization, no matter what their age. While population control reveals a national concern, Family Planning is strictly restricted to decision making at family level. Reproductive rights14: Basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health. It is the responsibility of the state to protect and fulfil the reproductive rights of its citizens. Rights to Protection and Freedom from Discrimination14: Outsourcing the work to private clinics, a move that has raised concerns about poor and illiterate women of rural India being pressured or fooled into going under the knife without fully understanding the risks, consequences and alternatives. Government programmes designed to ‘attract’ women to undergo sterilization by giving incentives in return leads to limited access to information and adequate health services by placing women in a position in which they are not empowered to make an informed decision.’Quickly fix’ the population problem-in whose benefit14? Constraints on reproductive choices are exercised – many states in India provide female sterilization as the only ‘suitable’ option to limit childbearing for the socially marginalised sections of society including the dalits, while policies to check and control child bearing patterns of the more affluent or better educated sections of society generally are not created. If people prefer a particular method over others14: A newly married couple may need a spacing method while a couple completing their family size may opt for a permanent method. But if one method is preferred over all the others, it is often due to poor information and knowledge about other options, limited access to services, cost factors or myths and misconceptions. Often, it also reflects aggressive promotion of a particular method by service providers concerned about meeting programme targets. For sustained decline in fertility rates, it is imperative that we have a more balanced ” method mix”. Ideally, a couple should consider both methods. If both are acceptable to the couple, vasectomy would be preferable because it is simpler, safer, easier, and less discomforting than female sterilization. Gap area: ‘Woman only’ focused sterilization12, 14: Female sterilization: most commonly used, the profile of the acceptors has changed from man to woman; and from a woman of over 30 years who has had 4 or 5 or more to a woman of 25 with 2 children. Use of condoms and vasectomy has been replaced by tubectomy and copper T usage. Surgical sterilizations resulting in women bleeding profusely due to medical complications; Surgical sterilizations being conducted on pregnant women, resulting in their deaths and/or in miscarriages. It is a very important question that why Female sterilisation as a family planning method is advertised and mostly in the society it’s the women who should go for sterilisation. It is very big issue of concern because in such taboo areas, lives the women with worst imagine situation without any right. The uncomfortable present scenario14: The GoI and Indian Council of Medical research (ICMR) has no published data on adverse outcomes of sterilization services even though 50 lakh operations are being conducted every year (mostly in camps) and ‘anecdotal evidences’ of failures and complications are very common6. Coercive nature of sterilization programme in India is extensively being reported from different states. Often those who are sterilized who had already met their family size. At national level, out of the total acceptors of female sterilization, 71% have not been informed about other methods of contraception before being sterilized. About one-third of the sterilized women at the national level have had follow-up visits by the health workers after sterilization. 17 percent of Indian women have suffered from at least one of the health problems after sterilization. The problems seem to be more among those sterilized in government health facilities (17 percent) compared to those sterilized in private health facilities (10 percent). Post-sterilization health problems reveals that health providers have not informed a majority of them about the possible health problems after sterilization (71 percent) coupled with poor follow-up visits (35 percent), questioning the quality of services.

Conclusion:

So far we have discussed many ethical issues along with the clinical and legal issues, mostly from India. From the above discussion, we can easily observe that there are many problems starting right from the individual level to his/her family to the medical practitioner to finally state or government level. The policies for Indian family planning programme started early in 1950s and by mid 1970s was the extreme point of violation of ethics of the individuals during Emergency. The present situation is not a bad as that, but we could not give as reason for such violations. Yes, we have very large population and it’s a big problem for the growth of the nation, but for the sake of growth of some individuals you can’t put the life of many in danger or violation of individual human rights. People should be very well informed of the process and consequences and both the partner should decide together after consulting Doctor, who’ll go for surgery and it must be a reasonable choice. As government is focussing on birth control, it’s his duty to provide better environment for such operations. Camp setting should be banned permanently because camps cannot replace the well managed health facility.

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