Quaeritur: Postpartum LARCs and mental illness

I was recently asked:

I recently looked up your article about encouraging a LARC for a drug addicted patient and your subsequent examination of conscience. I have a 27yo G2P1 bipolar patient with current benzo/meth/etc addiction who's 32 weeks and planning on getting a tubal ligation. I did not disagree with her decision, and was considering the morality of this. Did you ever find a conclusion to this "absurd state" of using contraception for those in addiction or mentally impaired patients (mental retardation, schizophrenia, etc)? Did you find any Catholic discussion regarding this? Humane Vitae and the discussion in Catholic Health Care Ethics book all are geared towards a typical person.

 Okay, let's take this apart. I want to say first that I did not encourage that patient in my blog post down any particular path. I never discussed postpartum family planning with her because we were always trying to ground her in the reality of her pregnancy and in circumstances surrounding her safety. It was only after my attending made a comment about contraception and I went to a St. Louis CMA guild event on LARCs in the mentally handicapped that I started to think about HV's possible limitations. (There's a post about that one, too, which you've probably seen.)

There is no good answer that I can find on this issue. The best that we came to at the guild event was temporary sterilization with filshie clips, but the Church is clear that not even temporary sterilization is acceptable. There are a few sets of articles from the Linacre that touch on it (from most to least relevant):

The articles that overtly deal with contraception in the mentally disabled adult or adolescent:

• Contraception for the Mentally Disabled: A Contraceptive Act? (Napier, 2013)This paper argues that in certain circumstances, a Catholic institution that cares for disabled persons can ensure that some of them conform to a temporary sterilizing intervention. The argument proceeds by observing that the Church permits temporary sterilizing interventions for rape victims, because such interventions are not contraceptive acts, but rather, acts of defense. For similar reasons, some mentally disabled persons cannot consent to sexual intercourse and since rape is defined as unconsensual intercourse, some mentally disabled persons are proper candidates of temporary sterilizing interventions. These interventions do not count as contraceptive acts either. This is the case even if the disabled person in question desires the intercourse. This is so because consent is an intellectual act and desire is a passion. Desire does not entail consent. Although the conclusion reached may look "liberal" or "heretical" the argument shows that it is consistent with firm Church teaching.
• The demands of human dignity: Sexuality in the young person with intellectual disabilities (Fernandes, 2014)The topic of sexuality among the disabled is often ignored within Catholic seminaries; within pediatrics, it is treated as a “problem” where the best solution is contraception or sterilization. In this article, the authors argue for an approach to sexuality in disabled youth that is grounded in the inherent dignity of the person, borne out of Christ's own humanity. Because sexuality is a part of the human person in his or her totality, it cannot be ignored or obscured; on the other hand, it cannot also be the overriding “problem” which defines them. Rather, by friendship, love, and covenantal solidarity with the disabled person, we can begin to set an example for them and for society that there are goods to be strived for beyond the physical. The demands of dignity require practical changes in seminary and medical education and practice.
• Contraceptives for Victims of Rape and for the Mentally Disabled: A Reply to Stephen Napier (Tollefson 2013)In this paper I argue for the following claims. First, contraceptive acts are intrinsically wrong, and not merely always wrong within the marital context. Second, in consequence, the defense of the administration of contraceptives in case of rape must be understood under the rubric of the principle of double effect. Third, the existence or threat of rape is therefore not a sufficient condition for the permissible administration of contraceptives; the intention must be upright. Fourth, in the case as described by Stephen Napier, the intention with which contraceptives would be administered is almost certainly contraceptive; thus this administration would be an instance of an intrinsically evil act. Recognition of why this is so is the key to understanding why, despite a prima facie agreement, as noted by Napier, between his own position and that of Germain Grisez, there is nevertheless a rather deep disagreement. I articulate that disagreement, and indicate why I believe the question has not been fully resolved by Napier's essay.

The use of hormones in sexually active patients

• No Justification for Using IUD to Treat Menorrhagia (Raviele)
• The Mirena® Levonorgestral-Releasing Intrauterine System and Its Application to the Treatment of Menorrhagia: A Moral Opinion (Mulligan)
• Levonorgestrel in cases of rape: How does it work? (Raviele 2014)
• Does levonorgestrel emergency contraceptive have a post-fertilization effect? A review of its mechanism of action (Peck et al, 2016)
• Mechanism of action of levonorgestrel emergency contraception (Kahlenborn et al, 2014)
• Appreciation for analysis of how levonorgestrel works and reservations with the use of meloxicam as emergency contraception (Schneider et al, 2016)

The HIV/condom debate

• “Validity” and “liceity” in conjugal acts: A reply to Stephen Napier on the HIV-condom debate (Arias)
• Condoms and HIV: The State of the Debate (Newton)
• The Missing Premise in the HIV-Condom Debate (Napier)
• Condoms and AIDS: Is the Pope Right or Just "Horrifically Ignorant"? (Wills)

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Question used with permission.

Whether to Consent for Tubal Ligation

The Hiding Place is the story of a Catholic watch maker who sheltered Jews during the Holocaust. She was taken to a concentration camp, where she was put to work on an assembly line. As a watch-maker, she took easily to the assembly of relay switches. Too easily. She recounts how her foreman, a fellow prisoner, reacted:

"Dear watch-lady! Can you not remember for whom you are working? These radios are for their fighter planes!" And reaching across me he would yank a wire from its housing or twist a tiny tube from an assembly. "Now solder them back wrong. And not so fast! You're over the day's quota already and it's not yet noon."

I am a pretty good intern. I can see seven postpartum patients in an hour and a half, consent half of them for circumcision, counsel half of them on family planning options, discharge half of them, write their orders, finish and route their notes appropriately, and present them coherently at morning rounds. I still miss a detail here and there. But overall, I'm pretty good at what I do.

I can even consent for tubal ligation and arrange the paperwork for the two different states in our catchment area. (I have previously opined that it is not morally wrong to consent patients for BTLs.) But should I be this awesome at hooking people up with sterilizations? Should I be making it harder for people to get BTLs and, for that matter, contraceptives?

"Dear intern!" I hear in my head, "Can you not remember for whom those sterilization papers/OCPs/LARCs work? Those break down marriage and the family!" Many thoughts have flown in the past few weeks about whether I should yank some wires. (Note that I am not comparing my attendings and fellow residents to Nazis. I am only opposed to sterilization, not the people who do it.)

Thanks to: ama.uk.com and uptodate

On one hand, it is not my legal right or my professional prerogative to interfere with choices made by competent persons. It's not only feminist hate crime, but it could probably be construed as malpractice to interfere with someone's BTL by not completing their paperwork in a timely and correct fashion before their discharge. Anyone suing according to standard of care would simply point to ACOG's Opinion 385 and say "Doctor, this Opinion is standard of care. You were not practicing according to standard of care."

On the other hand, a little slip in the paperwork and someone could be delayed in receiving a BTL just long enough to have a different thought about it. One in five women who choose BTL within a year of their delivery regret it. And permanent primary sterilization is a grave evil even if someone doesn't rethink it. Did Corrie ten Boom care whether she'd be punished for soldering the wires wrong?

In the end, I decided to apply the principles I apply to any other consent: I counsel completely and accurately, I give the patient time (e.g. I tell them to think about it and talk with at least one other family member on postpartum day 1 and/or 2) and I fill out the paperwork if the patient chooses on the last day I see her. I have had patients who say (after I talk with them), "I decided not to, I'll just go with the [other method, usually a LARC]." I'm not happy about the LARC, but I am full of joy that I can throw away their BTL consent and hope that they learn to appreciate their fertility in the time they've afforded themselves.

Some disagree with me about whether BTLs are good for women, and others disagree with any involvement in the process. But I doubt that many would disagree with my approach to postpartum tubal consents: I counsel completely, give the patient time to make their own, informed decision (and speak with the attending after I see them, who usually offers a different opinion). I then witness when they make this decision on a form for the state.

How to Consent for Tubal Ligation

There are two important things to discuss with patients when consenting for BTL: permanence and regret.

Permanence

Only 50-56% of women can have a child after a tubal reversal (26% if you're trying to reverse it after age 39). The largest study done on tubal ligation was a prospective, multicenter piece of research done by the CDC, and was called the CREST study. It found that people under the age of 30 are 3.5 to 18 times as likely to request reversal than those over 30 (of those sterilized between 18 and 24, 40.4% requested information on reversal).

Not all insurance pays for the reversal, either. 

Regret

The CREST study found that 14 years after BTL, there is a large amount of regret, especially among patients with certain characteristics. Here are the numbers for regret at 14 years:

• 20.3% of women who were 18-30 years old regretted their sterilization
• 21.7% of black women
• 20.4% of unmarried women
• 17.6% of women who chose BTL within a year of their last child's birth

Regret develops in a linear fashion, meaning that around 5% regret at 3 years, then 10% at 7, then 20% by 14 years. It's difficult to extrapolate 14 years over a lifetime, especially a woman's lifetime, which has a natural time of infertility that can bring on or increase pre-existing regrets.

When women are under the age of 30, black, unmarried, or choosing BTL within a year of delivery, I counsel them that about 1 in 5 women like them regret their decision to get a tubal ligation. I also stress that the real world is not like Friends, and BTLs are permanent. I recommend on pospartum day 1 (or during prenatal care) that they talk about the decision with their loved ones and look into LARCs (and natural methods, of course), which are reversible and can be just as effective.