Permanent Contraception: Ethical Issues and Considerations
Summary of Recommendations and Conclusions
- Respect for an individual patient’s reproductive autonomy should be the primary concern guiding permanent contraception provision and policy.
- Before providing permanent contraception, obstetrician–gynecologists should engage in shared decision making with their patient and include a discussion of the patient’s reproductive desires that places the patient’s wishes at the center of care. Patient counseling should include information about reversible alternatives and emphasize the permanence of these methods, with documentation of a specific discussion that the procedure will mean that the patient will not be able to spontaneously conceive in the future.
- Whenever appropriate, vasectomy should be discussed during patient counseling as an option with fewer risks and greater efficacy than female permanent contraception.
- Longitudinal counseling is important to minimize patient regret. It is also important to avoid paternalism by the health care professional. Respect for reproductive autonomy requires not imposing thresholds based on age or parity or both for permanent contraception.
- Coercive or forcible contraceptive practices are unethical and should never be provided.
- Obstetrician–gynecologists should consider their therapeutic and fiduciary roles in counseling and care recommendations and avoid actions based on individual biases about race, ethnicity, socioeconomic status, sexual orientation, and parenthood status, which can affect the interpretation of patients’ requests and influence the provision of care.
- When an adult patient is without capacity to make treatment decisions and permanent contraception is considered, the physician should engage with the patient to the extent to which it is possible to gain a better understanding of their needs. The physician also should consult with the patient’s surrogate to adopt a plan that promotes what is believed to be the patient’s best interests while, at the same time, preserving the patient’s reproductive autonomy to the maximum extent possible.
- Special procedural safeguards and oversights are needed when incarcerated patients request permanent contraception because of the possibility of coercion in the prison environment that impedes proper informed consent. Particular care should be taken to ensure that reversible methods have been made available to incarcerated patients and, ideally, that documentation of prior (pre-incarceration) request for permanent contraception exists.
- If individual physicians or institutions will not provide surgery for permanent contraception because of personal religious beliefs or institutional policy, the patient must be informed as early as possible. The patient must also be provided with an alternative form of contraception that is acceptable to the patient or must be referred elsewhere for care. When difficulties in meeting a postpartum permanent contraception request are anticipated and such surgery is desired by the patient, transfer of care for the remainder of pregnancy should be offered.
- Given the importance of reproductive autonomy, as well as the multiple barriers to equitable access to permanent contraception, permanent contraception should not be considered elective but a medically indicated, time-sensitive procedure.
Recommendation Grading
Disclaimer
Overview
Title
Permanent Contraception: Ethical Issues and Considerations
Authoring Organization
American College of Obstetricians and Gynecologists
Publication Month/Year
February 1, 2024
Last Updated Month/Year
February 19, 2024
Supplemental Implementation Tools
Document Type
Consensus
Country of Publication
US
Document Objectives
Permanent contraception is the most used method of contraception among women aged 15–49 years and is one of the most straightforward surgical procedures an obstetrician–gynecologist can perform. At the same time, this therapeutic option is enormously complex when considered from a historical, sociological, or ethical perspective. This Committee Statement reviews ethical issues related to permanent contraception using a reproductive justice framework. Ethical counseling and shared decision making for permanent contraception should adopt a nonjudgmental, patient-centered approach, using up-to-date information about permanent contraception procedures and alternatives. Obstetrician–gynecologists should strive to avoid bringing into the clinical encounter biases around gender, race, age, and class that affect thoughts on who should or should not become a parent. Obstetrician–gynecologists should also ensure that permanent contraception requests reflect each patient's wishes, come from a desire to permanently end childbearing, and come from a preference for permanent contraception over all reversible methods as well as permanent contraception for the male partner. When difficulties in meeting a postpartum permanent contraception request are anticipated and permanent contraception is desired by the patient, transfer of care for the remainder of pregnancy should be offered. ACOG recognizes the right of all patients to unimpeded access to permanent contraception as a way of ensuring health equity, but it is unclear how to craft policies that protect from coercion but also do not create barriers to autonomously desired care. Determining the ethical balance between access and safeguards will require a collaborative interdisciplinary approach that involves a variety of stakeholders with varying perspectives.
Inclusion Criteria
Female, Adult
Health Care Settings
Ambulatory
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Management, Prevention
Diseases/Conditions (MeSH)
D003267 - Contraception
Keywords
contraception, permanent contraception
Source Citation
Permanent Contraception: Ethical Issues and Considerations: ACOG Committee Statement No. 8. Obstet Gynecol. 2024 Feb 1;143(2):e31-e39. doi: 10.1097/AOG.0000000000005474. PMID: 38237165.