Ethics of a Mandatory Waiting Period for Female Sterilization

Abstract

Due to a history of coerced sterilization, a federal Medicaid sterilization policy mandates that a specific consent form be signed by a patient at least thirty days prior to when the patient undergoes sterilization. However, in contemporary obstetrical practice, the Medicaid sterilization policy serves as a policy‐level barrier to autonomously desired care. We review the clinical and ethical implications of the current Medicaid sterilization policy. After discussing the utility and impact of waiting periods for other surgical procedures, we explore the psychology of time required for decision‐making and consider scientific understanding of regret. We argue that the current Medicaid sterilization waiting period is clinically and ethically unjustifiable and that the policy ought to be revised in light of the goals, preferences, and concerns of the people most affected by it. While the need for continued protection against coercion remains, the current mandated waiting period does little to enforce the high‐quality shared decision‐making that is desired for sterilization counseling.

Medicaid and Fulfillment of Postpartum Permanent Contraception Requests

“…3 Although potentially having a preterm birth, having fewer children, or starting a new relationship may increase the risk of subsequent regret, patients should be free to ultimately make autonomous decisions about their health and health care. 28–30 Furthermore, given the increased likelihood of patients from minoritized races to have Medicaid insurance, it is also important to note the potential effects of implicit biases on the provision of permanent contraception. 28,31…”

“…3 Although potentially having a preterm birth, having fewer children, or starting a new relationship may increase the risk of subsequent regret, patients should be free to ultimately make autonomous decisions about their health and health care. [28][29][30] Furthermore, given the increased likelihood of patients from minoritized races to have Medicaid insurance, it is also important to note the potential effects of implicit biases on the provision of permanent contraception. 28,31 In our study, fewer than half of patients with Medicaid insurance with unfulfilled postpartum permanent contraception requests had valid Medicaid sterilization forms at the time of delivery, although most forms were valid by 42 days after delivery.…”

Contraceptive uptake in postpartum people with and without opioid use disorder and opioid use with co-occurring substance use

“…Currently, for people with Medicaid insurance who desire permanent sterilization, a thirty-day waiting period between the time of written informed consent and the procedure is required. While this policy was originally intended to prevent reproductive coercion and sterilization regret, it now serves as a policy-level barrier to autonomously desired care for low-income women ( Amalraj and Arora, 2022 ) that is not experienced by those with private insurance who are not subject to these same regulations ( Borrero et al, 2014 ).…”

Ethical and Legal Considerations for Sterilization Refusal in Nulliparous Women

“…23 Aside from this, there are no restrictions on sterilization in the United States based on age and child-free status. 24 The doctrine of informed consent concerns two questions: whether a patient is competent or capable to decide about sterilization 25 and whether their physician has disclosed and discussed with them relevant information so that they can make this decision. 26 In the context of elective sterilization, this means that, if a patient is capable of making a health care decision, a physician must abide by their decision regardless of whether they believe it ill advised.…”

“…23 Aside from this, there are no restrictions on sterilization in the United States based on age and child-free status. 24…”