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The role of anticipated decision regret and the patient's best interest in sterilisation and medically assisted reproduction
  1. Heidi Mertes
  1. Correspondence to Dr Heidi Mertes, Bioethics Institute Ghent, Ghent University, Blandijnberg 2, Gent 9000, Belgium; Heidi.Mertes{at}UGent.be

Abstract

There is a clear discrepancy in the way those who request medical assistance in pursuit of their reproductive choices are treated. On the one hand, women who request a sterilisation are urged to consider possible future regrets and are sometimes refused treatment in anticipation of such regrets. This is despite the fact that for all age ranges, the majority of women undergoing a sterilisation do not regret the decision. Moreover, women who are voluntarily childless are likely to have a happier and more gratifying life than parents. On the other hand, women who request fertility treatment are not urged to second guess their desire for parenthood. Although the fact that the probability of regret is expected to be higher in the former case than in the latter justifies this difference in treatment to a certain extent, the gap between the two different approaches is wider than it ought to be if we also take future well-being into consideration, instead of focussing exclusively on anticipated decision regret.

  • Reproductive Medicine
  • Sterilization

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Introduction

In May 2014, an opinion paper of a 27-year-old successful writer, Sofie Rozendaal, hit the headlines in the Netherlands and Belgium.1 Mrs Rozendaal is convinced that she does not want to have children, has tried several anticonception devices and pills but due to their side effects and impracticalities, she would prefer to be sterilised by tubal ligation. Her decision was not taken on a whim, she has discussed this extensively with her family and friends and although she cannot predict the future, she esteems the chance that she might ever come to regret her decision minimal. Yet, her gynaecologist refused to perform the sterilisation, based on her young age, the fact that she has been in a relationship with her partner for only 3 years and on statistics that 20% of women who request a sterilisation come to regret it later on. He called it a mutilation of her body in which he wanted to have no part, unless if there are serious health risks. He does make exceptions for women who already have children and are ‘perfectly happy’ with their family. Sofie Rozendaal answered her gynaecologist that she was in fact perfectly happy with her family (boyfriend, cat and two rabbits), to which he invited her to make a new appointment when she was older (and wiser no doubt). In the meantime, he referred her to a psychologist. This is not an isolated story, but rather one that pops up regularly in the media (recent examples include Lori Witt, Julie Palm, Bri Seeley, Holly Brockwell or Erin Iwamoto-Galusha telling their stories in the Chicago Tribune, Huffington Post, The Guardian and the Daily Mail). This anecdotal evidence is also confirmed by the research of Campbell,2 Richie3 and Lawrence et al.4 The same problem may be encountered by men requesting a vasectomy, especially at a young age and when childless, but as there is no scientific evidence to support this hypothesis, this paper will focus exclusively on women.

As previously noted by Benn and Lupton, the problem of certain women not gaining access to tubal ligation (especially when they are young and childless) cannot be reduced to a conflict between paternalism and respect for autonomy.5 The physician's paternalistic approach can be explained and justified based on two factors that the physician needs to take into account: the patient's long-term well-being and anticipated decision regret. These two factors appear to be overlapping criteria, in the sense that one would expect a negative impact on well-being to lead to regret, whereas regret is not expected to surface when there is a positive impact on well-being. However, as will be clarified below, in the case of reproductive decision-making, regret is not necessarily linked to a diminished level of well-being. This leads to an interesting question: how should the physician's professional judgement give due consideration to both anticipated decision regret and well-being? The request for sterilisation will be compared with the request for infertility treatment.

Why close a future option if you can leave it open?

Before starting this analysis, it is important to shortly address the objection that there are plenty of valid alternatives to sterilisation available, which leave more room for changing one's mind about wanting children and are therefore thought to be necessarily better.

First, regarding the permanent character of sterilisation, although spontaneous conception may become permanently impossible (‘may’, because a successful tubal ligation reversal is sometimes possible), in vitro fertilisation (IVF) does not. This means that if regrets do surface after sterilisation, they can be acted on. Of course, it will remain a pity that technological interventions are necessary for a self-inflicted condition, but keep in mind that ‘remedying’ the possible consequences of refusing a sterilisation request—an unwanted pregnancy or involuntary parenthood—is a lot more problematic (if at all possible). The weight of this last concern depends a lot on the availability and accessibility of alternative forms of contraception. Thurman and Janecek, for example, reported a very high pregnancy rate (46.7% within 1-year postpartum) in women who requested but did not receive a postpartum tubal ligation at a US clinic. Although their data do not offer conclusive evidence, both the refusal of sterilisation and the subsequent (most probably involuntary) pregnancy are likely due to limited financial means and limited healthcare access.6

Second, whereas in most cases alternative methods of birth control are indeed less radical and thus preferable over sterilisation, this is not always the case, as every anticonception alternative has its own disadvantages. The US Centers for Disease Control and Prevention reported that 47% of women using contraceptives have at some point discontinued use of a selected contraceptive method due to dissatisfaction.7 Hormonal treatments are well known to have harmful side effects, both physically and psychologically. Life-long condom use is impractical, unpleasant, condoms can rupture and some people are allergic to latex. Also, pills and condoms can be forgotten and lead to an unwanted pregnancy, etc. When going over all the pros and cons of the different anticonception methods for an individual woman, it is not evident at all that sterilisation cannot come out as the best option for some women, especially for those who fear having children, rather than fear not having children.

Regret

However, being a physician means more than catering to each and every patient request. Physicians swear an oath not to harm their patients and have the duty to keep their best interests in mind at all times. It is, therefore, the physician's professional duty to discuss the possibility of future regret with the patient, especially when she is statistically likely to regret her decision in the future. Lawrence et al4 reported that physicians' advice varies based on patient age, number of children and agreement of the partner. As the literature supports an (inverse) correlation between regret and age at sterilisation, the physician being cautious when a young woman presents herself for a tubal ligation can be said to be driven by a concern for her future well-being.8–10 However, a convincing correlation between number of children and regret after sterilisation has not been reported, so parity should not influence access to tubal ligation. Reported rates of regret after tubal ligation vary considerably. Looking at the most recent studies, Singh et al11 reported a 5% regret rate in sterilised married Indian women (aged 15–49 years). Hillis et al9 reported an average 12.7% regret rate 14 years after sterilisation, which increases to a 20.3% regret rate for women aged 18–30 at the time of sterilisation. A review by Curtis et al with studies conducted between 1983 and 2003 indicates rates for women undergoing sterilisation below the age of 30 from 10% to 36% and for women above 30 from 4.5% to ±19%.8 At the same time, instead of focusing on the minority that regrets the intervention, one might use the same statistics to point out to candidates for fertilisation that a majority do not regret the decision. This is true even for young, childless women. Moreover, many women who are dissuaded from the sterilisation or denied access may also have regrets later on.6 ,8 ,9

Yet, for the purpose of this article, suppose we take for granted that physicians have good reasons to be reluctant to sterilise women, based on the fact that a certain number of them will eventually come to regret it and that it is the physician's duty not to harm the patient. What is puzzling, then, is that the same reasoning is unthinkable in the related context of fertility treatment. Gynaecologists or fertility doctors do not have the habit of informing those who seek fertility treatment that having children may not be in their best interest, that life with children may turn out to be a lot more troublesome than life without children and that they may change their mind about the desirability of having children when they grow older and wiser or when they change relationships. If regrets are talked about at all in the fertility clinic, it is mainly in the sense that infertile couples should do everything they can to conceive a child in order to prevent future regrets.12–14 A refreshing counterexample is Judith Daniluk's research on regrets after (unsuccessful) fertility treatment.15 Although it is a painful experience for many people and although some report they regret not stopping their treatment earlier, the great majority of her research participants do not regret undergoing treatment as it offers closure for their unfulfilled desire for parenthood. This might be a first element in explaining why anticipated decision regret is less of a concern for a fertility treatment request than for a sterilisation request. At the same time, whereas there are numerous studies on the regrets of childless people and of those who are sterilised in the scientific literature, there are virtually no studies on the regrets of parents. A notable example is the 2015 study by Donath,16 in which 23 Israeli mothers regretting motherhood were interviewed. This is a lacuna that merits attention if we want young adults to make an informed decision on a life event of this magnitude and if we want physicians, gynaecologists, obstetricians, fertility doctors and psychologists to inform and counsel their patients properly. However, regretting parenthood is taboo, which was very well illustrated by the media and Twitter interest sparked by Donath's study and by the anecdotal case of Isabella Dutton's public confession.

In April 2013, she published an article in the Daily Mail, in which she writes that having children is the biggest regret of her life.17 Although she, like Sofie Rozendaal, had always realised that she had no desire whatsoever to become a mother and was perfectly happy without children, she eventually embarked on parenthood out of love for her husband, and hoped that ‘becoming a mum would cure (her) of (her) antipathy’. Alas. More than 1800 comments were posted online in response to her article. Some were understanding, but many were very harsh, describing her for instance as an ‘utterly miserable, cold-hearted and selfish woman’. Note that this woman loves her children, did not abandon them or treat them badly, she just realises that she would have enjoyed life more as a child-free woman. While she surely is an exception in reporting this (and possibly also in regretting parenthood), contrary to popular beliefs, she is not an exception in the sense that having children was not in her best interest (see below).

One cannot help but notice that there seems to be a widely shared (implicit) belief that childless people who regret not having children are right, whereas parents who regret having children are wrong. This belief, then, is translated to the gynaecologist's cabinet in the sense that there is a discrepancy between the level of scrutiny to which a request for sterilisation is subjected as opposed to a request for fertility treatment: those who say that they do not want to have children are mistaken, those who say that they do want to have children are right. How should this discrepancy be dealt with? Should doctors be less inquisitive towards young women asking to be sterilised? Should doctors be more inquisitive towards women asking for fertility treatment? Or is a different approach in fact justified, based on the best interest of the patient? This last option would only be acceptable if, for a majority of people, it is in their best interest to have children, rather than to remain childless, which seems to be a widespread assumption. But is this true?

Parenthood paradox

First of all, people with children tend to be happier than people without children.18 However, a correlation does not reveal cause and effect: does having children make people happy, do happy people have more children or is there a third confounding factor? At least for first-world countries, Billari concludes that happier people on average have more children, for the simple reason that a basic level of happiness is a requirement for having children in such societies.19 People preferably delay parenthood until they have, for example, a strong relationship, good housing and a fixed income, all factors that are positively correlated with happiness.20–22 Other findings from Billari are that the expected happiness increase is positively correlated with fertility when considered cross-country and that also on the individual level, the perception of an increase (or decrease) in one's own happiness from having a child is a key factor that influences the decision to have (or not have) a child. In fact, this perception is a very strong predictor of the decision to have a/another child: people have children because they think it will make them happier and a great majority of people have this belief.19 But are they right or are they mistaken?

A multitude of studies have been conducted on this topic and conflicting results have been reported, but overall, it appears that if there is any correlation between parenthood and happiness in the developed world, it is—contrary to prevailing beliefs—slightly negative, rather than positive.23 Some clarifications and nuances are in order to avoid misinterpretations of this finding. First, the claim is not that all parents are unhappy people, that the average parent is unhappy or even that the average parent is less happy than the average non-parent. As mentioned, the contrary is true: parents tend to be happier than non-parents.18 However, this can be attributed to factors other than parenthood, for example marital status.23 Happy people are thus more likely to have children and one might say—rather provokingly—that their level of well-being tends to remain above average despite having children, rather than because they have children. Second, the claim is not that parenthood has a negative effect on well-being across the entire population. A study by Galatzer-Levy et al, for example, found that the majority of individuals (84.2%) experience no long-term effects on life satisfaction in response to childbirth, while 7.2% experience a sustained decline and 4.3% demonstrate “dramatic and sustained improvements in response to parenthood” (p. 1), which on average seems to result in a slightly negative correlation.24 As evidence is inconclusive, we might even content ourselves with the lesser claim that parenthood is unlikely to have a positive effect on happiness, again, on average. Factors such as age, gender, marital status, level of education, socio-economic status and geographical location are all known variables. For example: whereas parenthood has a detrimental effect on the well-being of the average young, poor, single woman with primary education, it gives a boost to the well-being of the average married, highly educated, 35-year-old Scandinavian man.25 Yet, taking all these nuances into consideration, we can still conclude that the common belief that parenthood is the road to happiness is fundamentally flawed. Baumeister has dubbed this phenomenon the ‘parenthood paradox’ and puts forward a possible explanation: “People want to be happy, but they also want life to be meaningful. Having children makes life much more meaningful, even if it does diminish happiness”.26 Lyubomirsky and Boehm have a similar hypothesis that “despite the apparent disparity in well-being between parents and nonparents, current measures of happiness may be unable to gauge the more powerful and profound—and literally immeasurable—ways that children enhance an individual's life”.27

A first distinction might be made between happiness and life satisfaction, whereby happiness relates more to what is called ‘affective well-being’ and life satisfaction to ‘cognitive well-being’. Studies looking at life satisfaction, however, show a similar trend as the happiness studies: life satisfaction peaks in anticipation of the birth of the first child but drops sharply in the first years thereafter, especially for women.25 ,28 ,29 Five years later, life satisfaction is back at the baseline level.

A report by the UK's Office for National Statistics makes an additional distinction between happiness (“Overall, how happy did you feel yesterday?”), life satisfaction (“Overall, how satisfied are you with your life nowadays?”) and meaningfulness (“Overall, to what extent do you feel the things you do in your life are worthwhile?”).30 This report shows that although there is no significant difference between the average ratings for life satisfaction and happiness between people who live in households with children and those who live in households without children, there was a small but significant difference on the question to what extent the things they do in life were worthwhile, suggesting that parents rate their lives as slightly more worthwhile than people without children. This is not really surprising. Whereas the first two questions refer only to the individual herself, the third question seems to take a broader perspective, in the sense that one might add ‘for yourself and others’ to the last question, but not to the first two. The mere fact that I esteem that raising my children is worthwhile for my children in addition to its meaningfulness for myself may already explain the difference between the other two questions. But what is more interesting: the fact that parents rate their lives as more worthwhile is apparently not reflected in their life satisfaction. This indicates that meaningfulness may not be as important as Baumeister would have us believe.

Regret or well-being?

From the above, it appears that many people may be too optimistic about the benefits of parenthood. So returning to the question whether it is okay for a physician to subject requests for sterilisation and fertility treatment to a different level of scrutiny, we come to an inconsistent conclusion. Based on anticipated decision regret, physicians should be more reluctant to honour sterilisation requests, but based on anticipated well-being, they should be more reluctant to honour requests for assisted conception. If physicians consider it to be their duty to check if patients have given due consideration to possible future regrets in the case of a sterilisation request, they should equally consider it their duty to check if patients who request fertility treatment have given due consideration to the impact of parenthood on their lives.

Regret and well-being are pulling in opposite directions, in the sense that although having children might not have a positive effect on well-being, people may nevertheless be more likely to regret childlessness than parenthood. It logically follows from the mentioned findings from Billari19 that the (false) belief in a positive correlation between parenthood and happiness is widespread, that many people will regret childlessness despite the fact that there is little reason for this regret and that few people regret having children despite the fact that their well-being would have been higher had they not had children. The latter observation is all the more true as once the children are born it is very difficult to imagine a situation in which one would never have had those children.16 In this sense, it is probably true that the chances of parents actually regretting parenthood are smaller than the chances of sterilised women regretting their sterilisation, although there are currently no empirical data to confirm this hypothesis. Moreover, regrets are even less likely in IVF patients who become parents than in the general population as they are found to be remarkably resistant to the child-related stressors that cause the dip in well-being at childbirth for the average parents.31 Ironically, opposed to the general population, infertile people—especially women—on average do experience an improvement in their well-being when they make the transition to parenthood.32 One possible explanation is that in the general population, many children result from unplanned and/or unwanted pregnancies, so many parents did not desire parenthood in the first place. Another explanation may be found in cognitive dissonance theory.33 People who have gone through years of physical and emotional hardship and might have invested a lot of money in their pursuit of having a child are very unlikely to question whether their lives have improved after finally obtaining the goal that they pursued so passionately. Or, on a more positive note, one might say that those people appreciate the joys of parenthood more than those who did not struggle to become a parent. These observations, together with the findings that also people who underwent fertility treatment unsuccessfully still did not regret it,15 would explain and justify why fertility doctors do not consider possible future regrets or diminished well-being as a contraindication for treating their patients.

However, this does not justify the barriers that women face when they want to prevent parenthood by sterilisation. Based on all the research looking into the relation between happiness, life satisfaction and meaningfulness, we concluded that rationally, there is no reason for childless people to regret their childlessness, as remaining childless very likely served their interests and maximised their well-being. Just as the decision to have children is largely based on the false belief that parenthood will make people happier, regrets in the childless population are likely to be based on that same false belief. The stigma on childlessness and social pressure to adhere to traditional family norms may be a second factor contributing to regrets, although it must be mentioned that in a number of developed countries, the acceptance of voluntary childlessness has risen tremendously in the last few decades, along with the perception that childless people can have meaningful lives.34 ,35 This increased acceptance should also find its way to the gynaecologist's cabinet. Although it is to a certain degree understandable that gynaecologists are more reluctant to destroy a patient's fertility than to enhance it, it is important that patients do not become the victim of their physician's prejudices towards childlessness and that they receive adequate care. Women—especially when they are young and childless—should be counselled about the possible permanency of the procedure and about less invasive alternatives. At the same time, they should also get a positive message that most women who opt for sterilisation are happy with their decision and that research shows that the voluntarily childfree have the greatest chance of achieving a high degree of subjective well-being and life satisfaction. In any case, they should not receive a message that their decision to embark on a child-free life is somehow wrong or troubling.

Conclusion

There is a clear discrepancy in the way anticipated decision regret and the duty to do no harm are appealed to in reproductive medicine. On the one hand, women who request a sterilisation are urged to consider possible future regrets and are sometimes refused treatment in anticipation of such regrets, especially at a young age and if childless. This is despite the fact that for all age ranges, the majority of women undergoing a sterilisation do not regret the decision and those who do still have a chance of regaining their fertility through a tubal ligation reversal or IVF. Moreover, women who are voluntarily childless are likely to have a happier and more satisfying life than parents. On the other hand, women who request fertility treatment are not urged to second guess their desire for parenthood, while research shows that this desire is largely based on the flawed belief that parenthood will make them happier. Although the fact that the probability of regret is expected to be higher in the former case than in the latter justifies this difference in treatment to a certain extent, the aim of this paper is to show that the gap between the two different approaches is in fact wider than it ought to be. Although more regret is reported after sterilisation than after childbirth, this does not mean that people are better off with than without children. Thus, if we give due consideration to the best interest of the patient, rather than focusing exclusively on anticipated decision regret, the discrepancy between the support that is given to people who either chose for or against parenthood is not justified. Hopefully, we will see two evolutions in the future. First, that those who want to become parents are more actively challenged to weigh the pros and cons of this important life decision, in the context of reproductive medicine and (especially) also in the general population. Second, that those who do not want to become parents get more credit for their choice. They are not jeopardising their well-being any more (even less) than those who opt to become parents.

References

Footnotes

  • Contributors HM conceived, drafted, revised and submitted this manuscript.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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