A 17-year-old female patient with a history of mental retardation presents to your clinic with her mother. The mother states that she wants her daughter to have a bilateral tubal ligation after she recently discovered her looking at pornographic materials. She states that her daughter is not capable of understanding the repercussions of sexual intercourse, and that she does not want her to be burdened with a child that she would not be able to raise. Upon discussions with the patient, it is clear that she is not able to understand that sexual intercourse can lead to pregnancy. What should your next step be?
- Schedule the patient for the requested surgery
- Wait until the patient is 18 years old, and then schedule for surgery
- Refuse the procedure because it violates the ethical principle of autonomy
- Refer the patient to a psychiatrist to get informed consent
- Refuse the procedure because it is unlikely that the patient will get pregnant
In all patients, regardless of mental disability, the ethical principles of autonomy, beneficence, nonmaleficence, and justice should be respected. Treatments such as sterilization are unlikely to respect these core principles unless desired by the patient.
Beneficence is an obligation to act in the best interests of the patient. Autonomy is an individual’s right to self determination. A related concern involves capacity - whether or not a patient has the ability to make an informed decision in his or her own best interests. How to determine if a patient has capacity depends on the the relative risk/benefit of receiving or not receiving the procedure or treatment. In this case, the patient likely does not have capacity to give informed consent. Regardless, autonomy is an important concern, and is typically considered to be more important than beneficence.
Tunzi says that typically, to limit autonomy, one has to demonstrate that the patient’s decision will result in irreversible harm that was not intended. He also states that capacity exists on a sliding-scale that depends on the degree of risk or benefit available.
Weisleder gives an example of a case of a male patient with trisomy 21 whose parents requested he undergo a vasectomy. The parents were worried that they would be left with the financial obligation of raising a child as the patient would be unable to raise a child himself. The case went to court, which decided that despite the patient’s lack of capacity, the sterilization procedure was not in the patient’s best interest and so should not be performed.
Illustration A from Tunzi provides an algorithm for determining whether capacity should be assessed or evaluated. It demonstrates that certain risk benefit thresholds should be crossed before further assessment is necessary.