I recently attended a seminar concerned with human rights violations of women forced or coerced into sterilisation, a joint undertaking by the Open Society Institute and the International Federation of Health and Human Rights Organisations. For a week I was a guest in a handsome villa in snow-softened Salzburg with health professionals and human rights activists from across the globe. Although the focus of the meeting was on eliminating the practice, fairly early on the tricky issue of spousal consent emerged. In some cultures either custom or law – sometimes both – dictate that a married person can only request sterilisation with the consent of his or her spouse. Human rights law – and much of bioethics – regard such a practice as a violation of autonomy rights. Several doctors from the south though were rendered uneasy by the strength of the denunciation. The simple assertion of autonomy rights in cultures where spousal consent was the norm did not necessarily lead to benign outcomes. Medicine, they argued needed to be seen as a practice embedded in and sympathetic with – though not uncritical of – culture, not standing in lofty opposition. Besides, wasn’t there a flavour of ethical imperialism here, western values cloaking themselves in the garb of universalism?
As the only ethicist to hand, I was invited to facilitate a meeting to try and bring the differing camps into dialogue. With considerable misgiving I agreed. I started out with what I thought were the strong versions of both claims. The autonomy argument, native to me and familiar to most in the west who think about such things, is close to locating absolute value in the right of an adult to determine her life – the right of the individual, that is, is prior to any normative notion of a good life. Some cultures however do not approach things in this way. The value of life is seen as far more embedded in relationship and community than in the exercise of individual choice. The effects of a decision by a married man or woman to be sterilised are not confined to the individual. Good is less a matter of autonomous decision and more a matter of something found or revealed within the lives we live. In such a view, cultural norms, while they may not be determinative, nonetheless deserve greater consideration. How then to proceed?
I began where I usually begin when I try and think about such things, by suggesting that cultures are seldom monoliths. They change. They respond to internal and external critique. Communitarians in the west raise concerns about the implications of the pre-eminence of rights; women’s groups in the south condemn spousal consent for restricting women’s rights to self-determination. Superficial differences between cultures can also veil shared values. Herodotus nicely points out that those who burn their dead are appalled by those who eat them, but step back a little and both can seem like forms of respect – for both the living and the dead. Cultures can sometimes legitimately be seen as different paths to shared goals.
So far so good, but keen to bring the debate down a little from the lofty heights of theory we took up a case that had been raised earlier in the seminar. A gynaecologist in Germany was approached by a woman recently naturalised and seeking a sterilisation. She had had four children and was informed by doctors that any more would present a significant risk to her life. Her husband, however, insisted she continue adding to the family. The gynaecologist agreed to the sterilisation and made it very clear to the woman that medical information was confidential and that she had an absolute right to choose how to manage it. What I suggested we did was to transpose this scenario into a culture where spousal consent was the norm. And then I posed a question. Assume that spousal consent was required. Assume further that it was not forthcoming and that the woman in question was returned to her reproductive fate. Did any of the assembled clinicians think that this was a benign outcome? They did not. Science may aspire to value-neutrality but the data it generates can be transformative. Presented by medicine with the near-certain outcome of future children, a respect for the wishes of the spouse was ranged against the deep interests of the mother and nobody at the seminar would defend it to the end.
Julian Sheather is ethics manager, BMA. The views he expresses in his blog posts are entirely his own.