The ethics of State-sponsored and clinical promotion of long-acting reversible contraception

Originally published in the BMJ Sexual and Reproductive Health Blog.

By Jeffrey Wale and Sam Rowlands.

Global responses to the Covid-19 pandemic offer a good opportunity to re-examine the role of State actors (policymakers, regulatory bodies, clinical commissioning groups, service providers) and healthcare professionals in the promotion of health-related behaviours.  Just how far should healthcare professionals go in promoting, persuading, and influencing ‘good’ behaviours in the patient encounter?  Who decides what is ‘good’ and how far should resource considerations shape the informational exchange process and the recommendations made to individual patients?

Our article uses long-acting reversible contraception (LARC) as the fulcrum to address these issues.  There has been a tendency for the public and clinical narrative to emphasise the simplicity and long-term duration of effect, and to treat LARC as an unqualified good for all.  Sure, LARC provides a valuable and effective contraceptive option for many users, but some individuals do experience difficulties during and after use.  Low risk does not equate with no risk; and effectiveness may be less valuable than immediate control for some users. The positives of LARC methods are often seized upon in jurisdictions keen to promote efficacious and reliable contraceptive options for their population. There has also been a tendency to discuss LARC as a singular unified option, when the reality is a diverse range of methods that work upon the human body in different ways.  This can have ramifications for the resulting discourse.

In terms of the State promotion of LARC methods, there are two central concerns.  What reasons or motives underpin the active promotion of any specific contraceptive option?  In many ways, it is easier to identify ‘bad’ motives that count against promotion.  We know that LARC methods can be promoted to vulnerable demographic groups without due regard for individual circumstances, values or wishes.  Discriminatory targeting is likely to be problematic, if user autonomy is recognised and valued to any real extent.  Second, we should be concerned by the degree to which State actors are honest, transparent, and consistent in any public narrative about LARC use and promotion.  Is the central message one of respect for user autonomy or responsible family spacing or parenting? The normative messaging behind responsible parenting, implicitly prioritises impersonal and consequential considerations over the enhancement of individual choice.  Here the emphasis is on societal obligations and consequences, rather than the importance of individual values and priorities.

At a local level, healthcare professionals are often placed in an invidious position.  On one side, there may be pressure at an organisational or executive level to promote certain behaviours in their patient or user populations.  On the other, they will owe distinct professional obligations to potential and existing users.  Here the relationship is of a different kind.   State actors have an anonymous and remote relationship with the end user.  Healthcare professionals ought to and are likely to have a much closer and trust laden relationship with an identifiable individual. We argue that imposing a dual responsibility upon healthcare professionals for raising awareness/ informational exchange and the active promotion of LARC, creates an unnecessary tension and barrier for the delivery of patient-centred care.  It is paramount that healthcare professionals acknowledge this and do not make the questionable assumption that every user will be influenced solely by the relative effectiveness of any given contraceptive method.  Ultimately, what matters is a balanced narrative and information sharing programme that respects the individual interests and priorities of each contraceptive user.

Paper title: The ethics of state-sponsored and clinical promotion of long-acting reversible contraception

Authors: By Jeffrey Wale and Sam Rowlands

Affiliations: Bournemouth University

Competing interests: SR has received fees for acting as a trainer and for giving lectures on behalf of companies that market long-acting reversible contraception (LARC) products.

Social media accounts: @rowlands999  @bournemouthuni

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