By Sheldon Berkowitz, MD, FAAP
Sterilization of minors is an uncommon procedure in pediatric practices, but an important one to understand if a family requests information about it. This article will help to understand what the ethical issues are and how to proceed if it is requested for your patient. Typically, this issue is only brought up for our patients with complex health care needs for whom it is felt that pregnancy (or fatherhood) would present significant problems for your patient or the potential offspring.
The background of this subject and the main reason why there has been so much oversight provided is that in the past, eugenics and other movements to limit reproduction of certain elements of our society led to mistreatment of our most vulnerable patients. The desire to prevent patients with diagnoses such as Trisomy 21 or mental retardation from procreating and potentially bringing more children with these problems into the population resulted in young adults being sterilized, often without any oversight as to whether this was the right thing to do or not.
As a result of these abuses of the medical system, both the American Academy of Pediatrics (AAP) and the American College of OBGYN (ACOG) have published policy statements on when and how minors can undergo sterilization. The goal of these policy statements is to protect the rights of minor patients who may not be able to speak for themselves and to limit possible harm to them if the procedure is not indicated. Because minor patients cannot legally consent to invasive procedures, their parents are given the right as surrogate decision makers to make decisions for them – as long as they are acting in the best interests of their child.
Children’s Minnesota Ethics Committee first developed a policy on Permanent Sterilization of Minors In Non-life-threatening Conditions in 2005 and revised it in 2016. The process is designed to make sure that other, non-permanent options are considered first (primarily for females) and the best interests of the minor patient are protected.
For female patients, generally the issue is a desire on the part of the parents to make sure their daughter can never become pregnant (especially when the patient would never be able to care for a child and/or would be considered a vulnerable adult and at risk of being sexually abused and becoming pregnant). However, occasionally the issue has been around menstrual suppression, although this is less common now with improved pharmacologic methods to accomplish this.
For males, the main issue is a parental perception that their son would never be able to care for a child, typically due to significant mental impairment.
The process for having a patient approved to undergo a permanent sterilization at Children’s involves multiple steps (and may take 6 months to accomplish) including obtaining supporting documentation from the following:
• Primary clinician explaining why the planned procedure is necessary
• Psychologist explaining cognitive functioning of the patient and patient’s capacity to be involved in decision making
• Social worker explaining whether patient would ever be able to care for a child
• Gynecologist or Surgeon discussing what other less invasive methods have been attempted to achieve the desired goal and what procedure is being recommended
• Parents explanation of why they are requesting the procedure for their child
• Patient thoughts (if appropriate)
Once all of the above documents have been collected, they are forwarded to our Clinical Ethics Department for final review and then to Children’s Chief Medical Officer for final “sign off,”prior to surgery being scheduled.
If the patient is less than 18 years old, court involvement is not necessary. However, if the patient is 18 years old or older, court involvement may be necessary, especially if the parents have not been granted guardianship by the courts.
When faced with a decision regarding sterilization of minors, pediatricians should reference the AAP policy statements, discuss the case with Ob/Gyn or Urology, and consider engaging their ethics consultants.
If you have any questions, please feel free to contact me at Sheldon.firstname.lastname@example.org.