British journal of Urology (1995). 76, 103-105

Ethical issues in male sterilization in developing countries S.A.H. RIZVI, S.A.A. NAQVI and Z. HUSSAIN Sindh Institute of Urology and Transplantation, Dow Medical College and Civil Hospital, Karachi, Pakistan

Introduction

The present world population of over 5 billion is projected to rise to 10 billion by the year 2050. About 95% of the present population growth is in the developing countries. The global economic situation is that developing coun- tries generate only 15% of the world’s gross national product (GNP). Over 1 billion people in these regions live in absolute poverty and 600 million on the margin of starvation. On the other hand, developed countries with 23% of the world population account for 85% of the world’s GNP; following the ‘Malthusian’ concept which states that the population will increase in geo- metric progression while resources increase only in arithmetic progression, it will eventually become imposs- ible to sustain this population.

High fertility over a long period has negative effects on social and economic circumstances, e.g. those relating to health, education and income, as well as on natural resources and the environment. Over-crowded cities, over-strained social services, a poor economy, massive unemployment and an unchecked growth is impoverishing the developing nations. As all these factors are directly related to unregulated population growth, family planning becomes a basic pre-requisite for any kind of development to take place. Effective measures are urgently required to slow down the growth rate, to approach an equilibrium with oppor- tunity for growth [l] .

In developing countries, the value placed upon large families in the underprivileged section of the population is considerable and they are thought to be an economic asset: more children equates with more economic ‘units’. Infant mortality in these regions is high and the general belief is that it is desirable to have more children to ensure that more survive in the long run.

Historical background

Sterilization has a long historical background and, in the time of Hippocrates, female sterilization was advised to prevent the perpetuation of mental disease. James Blundell6rst introduced surgical sterilization in 1823 to protect women from further pregnancies which were hazardous to their health.

Vasectomy as a means of sterilization was reported by Sharp in 1897, and the first surgical procedure was performed in the USA. In those early years, the use of vasoligation and vasoresection was limited to eugenic considerations to prevent undesirable hereditary dis- orders, especially mental disorders. During the period from 1920 to 1945, vasectomy was advocated by Steneich as a method of sexual rejuvenation. Male sterilization came into disrepute during the Nazi rule in Germany because it was being employed as a means of genocide.

Religious issues Religious factors comprise the largest proportion of the reasons for not practising family planning. On the issue of contraception and sterilization, some religions, for example Buddhism and Hinduism, have no sacred texts. Hindus generally believe in Gandhi’s interpretation that marriage was a means of procreation, and abstinence would cause no harm as sexual energy would be trans- formed into spiritual energy.

The teachings of Islam, Christianity and Judaism have been commented upon for centuries by religious auth- orities, yet no specific edicts prohibiting contraception are quoted. However, some religious guidelines are inter- preted as prohibiting the use of contraceptives [Z]. Most Muslim theologians have strongly supported the Egyptian view and Iranian Ja’ferite view that there is no difference between sterilization and other explicitly sanc- tioned methods of birth control. However, Malaysian Fatwas and the Academy of A1 Azher in Egypt have taken a stricter view of limiting sterilization to situations of ‘personal necessity’ [3].

The Roman Catholic church considered a doctrine that the sole purpose of marriage was procreation and contraception was prohibited as it precluded pro- creation. Gradually, a slow change took place in various Christian communities and several European and American countries publicly abandoned the absolute prohibition of contraception culminating in a pro- nouncement by the World Council of Churches. Therefore, awareness, information, education, avail- ability of family planning services, mode of contact, types and quality of available services and above all,

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104 S.A.H. RIZVI rt al.

interest in using contraceptive methods are essential after allaying religious fears [4].

Voluntarism

As expressed in the world population plan of action and endorsed by the world community, ‘all couples and individuals have the basic right to decide freely and responsibly the number and spacing of their children, and to have the information, education and means to do so’. This right is also expressed in the convention of the elimination of all forms of discrimination against women ratified by 87 countries [5].

The right of family planning has two components: one is the right of individuals and couples to make free informed choices without pressure to accept family plan- ning, the other is the right of individuals and couples to have ready access to information and services without undue constraints [6]. It is important that policies be developed to protect voluntarism in the choice and practice of family planning.

It is recognized that the individual right of family planning must be harmonized with collective responsi- bility, i.e. it should be complementary not competitive or compulsory. Therefore, for a successful programme, voluntarism is to be assured by ensuring information and education [ 71, provision of services, benefits to health personnel who provide services and benefits to persons who choose specific family planning methods.

Laws and regulations

Voluntary sterilization is the single most effective method of fertility control. This is important and relevant in developing countries where population growth consti- tutes a formidable challenge to development. Few coun- tries prohibit sterilization by statute or constitutional provisions. In Europe and North America, sterilization is legal, except in some countries including Italy, France and Turkey. In Latin America, sterilization is illegal in many countries. In Asia, Burma and Vietnam place restrictions on sterilization but several countries have government-sponsored sterilization programmes. In Africa, fertility regulation is illegal in one-third of the countries. Some countries are pro-natalist, others have neutral policies and yet others adopt policies that actively sponsor a range of family-planning services. Legal issues may be less important than supposed and sterilization is taking place in countries with restrictive laws where physicians justify its use on scientific or humanitarian grounds.

Counselling and informed consent

Informed consent for surgical contraception is essential and is in fact the legal authorization for the procedure to be performed. The best way to assure that individuals make informed, well-considered and voluntary decisions is to require that all of them receive comprehensive pre- operative counselling by a skilled, unbiased counsellor. Thus, vasectomy should be introduced as a permanent procedure because reversal, even if successful, may affect the quality of sperms, due to antisperm antibodies.

Information and education must be accurate and factual and not biased towards any specific contraceptive method. Written information is preferred to verbal com- munication so that the important facts can be studied repeatedly, including material to counteract mis- information. Involvement of both male and female workers is to be encouraged.

Facilities

Due to economic factors or the un-availability of trained personnel it may not be possible to provide a full range of facilities for contraceptive measures, and developing countries may have to rely on a referral system to make all options available to everyone.

Central and regional targets are necessary for plan- ning, but local or method-specific targets should be avoided as they can threaten voluntary choice. Moreover, targets should not attach rewards or punish- ments to the fulfillment of these targets. When specific ethnic, racial or socio-economic groups arc targeted. serious ethical questions arise [S].

All family planning services should be an integrated part of the national healthcare system and voluntary surgical contraception services, if they provide incentives, should not be linked to the number of cases. as these interests or incentives may compromise voluntarism 3 I . India became a world leader in sterilization and millions of men, mostly illiterate villagers, underwent vasectomy. Voluntarism was sometimes overstepped.

Eligibility requirements

To ensure that the person is legally competent and mature enough to make the decision and to minimize the risks of subsequent regret or a bad psychological adjustment after surgery, most programmes require a minimum age and a minimum number of children, marital status and spousal consent. Special permission is required for those with only one child. A waiting period of 1-30 days after signing a consent has been recommended, and has been objected to by the critics. The exclusion of single and childless individuals, those

British Journal of Urology (1995), 76. Suppl. 2 . 103-105

ETHICAL ISSUES I N MALE STERILIZATION 105

under a specified age or without spousal consent has been challenged as a violation of human rights.

Informed consent should not be obtained when the individual is under sedation, or the effect of medications, or in the stress of pregnancy or of labour, as these may influence the person’s decision.

Individuals who are so severely mentally retarded or mentally ill that their judgment or comprehension is impaired, and who cannot function independently, should be prohibited from undergoing surgical contra- ception. Parents or guardians are empowered to give substitute consent on their behalf. However, it is ques- tionable as to whether this responsibility should be imposed on them. Surgical contraception may be an appropriate option for disabled persons who are incapable of caring for children.

Ethical issues in the future

Since the likelihood is remote that a male oral contracep- tive will become available, surgical contraception holds the promise of the best option for sterilization for family planning.

Vasectomy, despite the very low morbidity associated with the procedure compared with female surgical steril- ization, remains unpopular amongst males because of the genuine problems of reversal. As a result, the ratio of female to male sterilization worldwide is currently 3 : 1.

Vaccination as a means of fertility control is being hotly pursued and may become a reliable option by the turn of the century. The most fascinating technology however, is the introduction of cryopreservation of sperms before vasectomy. Thus, sperm frozen at - 196°C and later thawed could be used through artificial insemi- nation with no difficulty, although the quality of sperms thus obtained appears lower than with fresh sperms. However, with intracytoplasmic sperm injection (ICSI), a single spermatozoon can be injected directly into the cytoplasm of an oocyte, giving a high rate of fertilization. Women inseminated with frozen sperms stored for over 10 years have given birth to normal children. The development of single-cell polymerase chain reaction (PCR) will make it possible to type and encode semen samples at the time of freezing and thawing, thus eliminating problems of mistaken identity. Thus, vasec- tomy coupled with semen storage will become a ‘revers- ible birth control’ method.

The question of property of cryopreserved semen will remain an ethical issue, especially after the death of the person whose sperms were stored during his lifetime. Moreover, a nagging fear that such sperm may be employed for purposes of unethical practices, e.g. eugen-

ics, cannot be entirely ruled out. An interesting dilemma arises when a man whose fertility is unknown requests a vasectomy. These ethical issues will remain un- answered until society is faced with such technological advances.

Moreover, such ‘hi-tech’ procedures would be extremely costly and would only be possible in affluent societies. What about the poorer countries in the developing world who are worst hit by the population explosion? Unless the fruits of fertility research become sufficiently economical to be of use in the more under- privileged nations, the population boom may well engulf the whole globe.

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Authors S.A.H. Rizvi, MBBS, FCPS. FRCS, FRCSEd, FRCP, Professor and

Director. Sindh Institute of Urology and Transplantation (SIUT), Dow Medical College and Civil Hospital, Karachi 74400, Pakistan.

S.A.A. Naqvi. MBBS, MCPS, MS. Professor of Urology, Sindh Institute of Urology and Transplantation (SIUT), Dow Medical College and Civil Hospital, Karachi 74400. Pakistan.

Z. Hussain, MBBS, MCPS, MS. Associate Professor of Urology, Sindh Institute of Urology and Transplantation (SIUT), Dow Medical College and Civil Hospital, Karachi 74400, Pakistan.

British Journal of Urology (1995). 76, Suppl. 2, 103-105