Policies and Practices in Iowa Hospitals Relating to Human Sterilization Nelle S. Noble, M.D.
Iowa hospitals regarding tubal ligation vary widely. To ascertain the facts questionnaires were sent in March, 1953, to all hospitals in the state. The questionnaire is reproduced in Fig. 1. Of the 176 hospitals queried, 153 replied. These 153 included 130 general hospitals; 6. tuberculosis hospitals; 7 hospitals for mental disease or deficiency; 3 private mental hospitals; 1 hospital primarily for college students; 1 reformatory hospital; and 5 osteopathic hospitals. Of the replying hospitals, 82 had special requirements applying to tubal ligation and vasectomy which do not apply to other operations; 26 had no such special requirements; the other 45 failed to answer this question.
REQUIREMENTS FOR STERILIZATION Establishment
The special requirements were established by a variety of groups, most commonly (32 institutions) by the medical staff or a committee of the medical staff; by the medical staff and the administration (12 institutions); or by the medical staff and the board of trustees (10 institutions). The administration itself established them in 6 institutions, the board of trustees in 5, and in 2, the administration and the board of trustees were the authoritative body. The moral law of the Roman Catholic Church, the medical staff, and the governing board established the requirements in 6 institutions. Two institutions reported that the requirements for sterilization were determined by the Board of Eugenics, indicating that they perform sterilizations 375
Are there requirements at your hospital applying to salpingectomy and vasectomy procedures which do not apply to other operations? Yes 0 No 0
By whom or what body were these requirements established? What officer or body or group is responsible for seeing that these requirements are carried out in your hospital?
Is the approval of more than one physician required? Yes 0 No 0
If so, how many? 0 From what medical specialties? Are there other requirements? Describe:
Are sterilization operations permitted for the following reasons: 1. Diseases of the reproductive organs? Yes 0 No D 2. Too many cesareans? Yes D No D 3. To prevent pregnancies which would be dangerous because of
diseases of the heart, kidneys or lungs? Yes D No D 4. To prevent the transmission of undesirable heredity? Yes 0
NoD 5. To prevent an excessive number of children? Yes D No D
REMARKS: Fig. 1.
Questionnaire to Iowa Hospitals.
Vol. 6, No.4, 1955
HUMAN STERILIZATION POLICIES
only by order of that board; 2 listed the Board of Eugenics, Bureau of Hospitals of the American Osteopathic Association, as authority for their requirements, 2 did not answer the question, and 3 obviously misunderstood it. Enforcement
Enforcement of the requirements for sterilization is usually carried out by the authority or authorities which established them. The medical staff was reported to be responsible in 32 hospitals; in 17, the medical staff and administration; and in 10, the administration alone. In 5 the nurse in charge of the surgery and/or director of nursing service was responsible; 4 hospitals left responsibility to the "owners and operators"; 3 each to medical and nursing staff and to administrator and nursing staff; 2 to administrator and medical and nursing staff; 2 to medical staff and board of trustees; and 1 each to administration and board of trustees and administration, board of trustees, and medical staff; 2 listed the board of trustees alone as authority. Approval and Consultation
In 79 of the 82 hospitals, the requirements for sterilization had to be approved by more than 1 physician; 39 required approval by 2 physicians, 15 required 3, 7 required 4, 1 required 6, and 1 required 10. Three did not state whether approval of more than 1 physician was required or not. In many institutions regulations frequently require consultation from specialists in fields other than the one originating the procedure. These vary widely from hospital to hospital depending upon which appropriate specialty is represented on the staff. When available, obstetrical, surgical, gynecological, or medical consultants are often called upon. Additional requirements sometimes imposed are signed consultation reports and signed requests of the husband and wife for the procedure. Roman Catholic Policy
Procedures which induce sterility are permitted in Roman Catholic hospitals only as an unavoidable incident to the immediate cure or amelioration of a serious pathologic condition for which a less drastic remedy is not. available. Thus in ectopic pregnancy the affected tube or part of a fallopian tube may be removed, even though the life of the fetus is indirectly terminated, provide.d postponement of the operation appreciably increases the
Fertility & Sterility
mother's danger. The rules are elaborated in a code of morals, "Code of the Catholic Hospital Association," published in Hospital Progress [March, 1949], and in the Moral Code for Catholic Hospitals in the Diocese of Davenport, published in pamphlet form in April, 1949. Several Roman Catholic hospitals referred to these codes rather than fill out the questionnaire in detail. Others of the same group indicated that sterilization operations were not permitted simply to prevent an excessive number of children, the transmission of undesirable heredity, or pregnancy which would be dangerous because of organic disease of the heart, kidney, or lung. There were some differences in their opinion as to whether sterilization operations should be permitted for "too many caesareans" or for "diseases of the reproductive organs"-perhaps because of differences in interpretation of the question. INDICATIONS FOR STERILIZATION
Five of the 100 non-Catholic general hospitals which replied to the questionnaire did not record their policies or views regarding the five indications queried under Question 5. The answers from the 95 hospitals that did reply contained replies varying from one extreme to the other, with all possible shades of opinion between. Thirty-three hospitals permit sterilization operations for all 5 reasons listed, while 6 of these non-Catholic general hospitals do not permit sterilization operations on the female for any reason. As stated, 5 hospitals had not made up their minds or had no occasion to do so. On the other hand, many had very decided views. Here are a few comments written at the bottom of the questionnaires: "N ot according to our by-laws, but the doctors do them." (Sterilizations for "excessive number of children.") "Have had very few ligations of tubes. Our doctors are most cooperative regarding sterilization, doing them only when best for patient's welfare." "If 5 children are alive and patient can prove financial difficulty or poor general health we can sterilize the female ..." "Tubal ligation following the second caesarean section does not require consultation." "What the doctor and patient agree on happens to go here, as they are the parties concerned." "It must be a diseased organ."
The most frequent comment was that any such operation must be for a good "medical reason."
O' •• 'EN
W,NNEBAGO I WORTH
BLACK MA WIC BUCHANAN
I-::-:-::=:+':=::--~~--t yy yyl
NN NNI IT
YY I DAVIS
NN I YN
DES MO .. ~ .. ~,
'-----'l~ F YY.
Fig. 2. Regions in the Iowa Hospital Plan in which sterilization operations are permitted for reasons other than pathology. The multicounty groups are the service regions in the Iowa Hospital plan. Each pair of letters represents a hospital replying to the questionnaire. The first letter (Y = Yes, No = No, - = No answer) indicates whether sterilization operations are permitted to prevent the transmission of undesirable heredity; the second letter indicates whether they are permitted to prevent an excessive number of children. The figure 1 indicates no hospital in that county; 2 indicates a hospital, but no reply to the questionnaire.
Fertility & Sterility
One Roman Catholic institution which checked "yes" for diseased reproductive organs but "no" to all other reasons for sterilization reported, "there are no restrictions on any surgery when indicated." A non-Catholic hospital wrote in: "Our physicians are free to act on these matters within the limits which a high standard of medical practice dictates." Mental Deficiency and Disease
A somewhat different problem is the surgical protection from parenthood of the mentally deficient and the mentally ill. In Iowa this is governed by a state law, administered by the State Board of Eugenics. After approval by the board, sterilization of such persons can be carried out at state expense. In practice, cases are considered by the board only after written consent has been secured from the patient; spouse, if any; and next of kin or guardian. Most of the applications for sterilization thus approved are of patients in state institutions for the mentally deficient or mentally ill; however, the law is also available to persons outside of institutions. ACCESSIBILITY OF STERILIZATION PROCEDURES
In spite of the limitations for nonmedical reasons imposed on this branch of surgery by many of the hospitals, a geographic analysis indicates that the citizens of Iowa have moderate freedom of access to protective sterilizations. As shown by the map (Fig. 2) each of the multicounty regions into which the state has been divided in the Iowa Hospital Plan contains at least 1 hospital in which sterilization is permitted for eugenic indications. In all but 1 of the regions-that in the northwest, comprising Buena Vista, Clay, Dickinson, Emmet, O'Brien, Osceola, Palo Alto, and Sac counties-there is at least 1 hospital where parents with an excessive number of children may secure surgical sterilization. The Iowa State Medical Society's Handbook of Resources Available to Physicians contains additional information regarding sterilization in the sections relating to the Human Betterment League of Iowa and to the Iowa State Board of Eugenics. 1050 25th St. Des Moines, Iowa