§ 12.6 a.m.
§ Mr. Frank Hooley (Sheffield, Heeley)
Problems concerning sexual relations bearing on children and family responsibilities are highly emotive and arouse a good deal of public concern, as witness the recent controversies on such subjects as rape and abortion. It is natural that this should be so, since reproduction is the basic biological phenomenon and affects the survival of the whole species, quite apart from the emotional and social overtones of sexual relations between men and women.
Sterilisation is as sensitive an issue in this area as any other since it arouses arguments about the individual's rights, doctors' rights, patients' rights, responsibilities of society at large and, of course, of this Legislature. The subject becomes peculiarly difficult and poignant when the sterilisation of a young child is under consideration.
So far the law has had nothing to say about sterilisation of children. For abortion, there are legal grounds laid down in the 1967 Act but there is no 630 statute law governing sterilisation, although under the Family Law Reform Act 1969 a parent's consent is necessary before any operation of any kind can be carried out on a child under the age of 16. Under the same Act sexual maturity could in some contexts outweigh the need for a parent's consent.
But the law has an indirect effect. Any doctor carrying out a sterilisation operation on a child, even with the parent's consent, could lay himself or herself open to an action for damages if the girl as an adult were subsequently to sue for being deprived of the chance of bearing children. This in itself could not remedy her condition of sterility, which might have damaging emotional or psychological consequences for her personality and inhibit the prospect of a satisfying marriage. There is in a sense a legal remedy if at a subsequent stage she were able to satisfy the court that the original operation had been unjustified or unnecessary.
As the situation stands, the protection of a child held by doctors to be too young to take her own decision lies partly in the hands of the parents—and I will return to that—but more in the medical profession's code of conduct and the individual doctor's reluctance to perform an unnecessary operation. There is apparently no way in which lay professionals, even administrators in the Department of Health and Social Security, can challenge the absolute autonomy of a doctor's clinical decision if the doctor chooses to disregard their views.
As far as I know, the doctor is under no obligation to seek the views of professional workers in other spheres, such as psychologists, especially qualified teachers or other persons who may be concerned with the child's welfare or education. This situation can clearly raise serious moral and legal dilemmas for any doctor faced with the decision whether to operate on the reproductive organs of a child too young or mentally incompetent to decide for herself.
The matter can be even more complicated because in some cases—and I have in mind one which has recently aroused particular public concern—there may even be a serious clash of medical opinion about the need for or the desirability of an operation of this kind. One doctor may claim that there might be a high 631 chance of the girl, if she ever became pregnant, producing an abnormal child. Another distinguished surgeon might equally claim that the chances of the girl producing a physically normal baby would be very good so far as it is possible to foresee.
Similarly there could be a clash of medical opinion whether the girl's condition was hereditary and whether sterilisation could be of any real value. In a recent case Professor Walter Bodmer, Professor of Genetics at Oxford University, was quoted as saying:Even if Sotos Syndrome were inherited—and that is a matter for doubt—it is a hopeless task to attempt to eliminate such conditions from the population by sterilisation of those who suffer from them. It would have virtually no effect in reducing the frequency of the condition in the population. This is because the number of people who manifest the condition is so small compared with the number of carriers who pass it on to their children but who are perfectly normal themselves.There is the question whether there is any ethical justification for eugenic sterilisation—namely, what has sometimes been called genetic engineering. Dr. Cederic Carter, Director of the Genetics Unit of the Medical Research Council, is quoted as saying:I would say there is no genetic justification for sterilising a girl of this age.That is the age of 11 years. He continues:I cannot think of a case where it would be justified. I would advise anyone to wait until the girl was old enough to give her own consent.If doctors themselves disagree, what about the rights of parents? That is clearly a matter of the greatest importance. Just as clinical freedom is intended for the benefit of the patient and not the doctor, so parents' rights are unchallenged only up to a certain point. The parent obviously is not allowed to batter or ill-treat a child without exposing himself or herself to legal reprisals. It could be argued that to sterilise a young child, even with parental consent, is an infringement of the fundamental human rights of the child itself which society should not permit under any conditions. Emphatically in my view no child should be sterilised because her offspring might at some future date be an inconvenient burden to society. The criterion must be the well-being of the child.
632 I believe that there is one point on which everyone—and I am sure this includes my hon. Friend the Minister of State, Department of Health and Social Security—will agree—namely, that a decision to carry out an operation of this nature on a child raises serious and fundamental questions of human rights and public policy and has fairly wide ramifications. For example, what attitude should we take in regard to a child who may be so mentally subnormal as never to be likely to be in a position to give or withhold consent on the basis of a clear understanding of what was proposed?
Secondly, there is the question of a child who may be in the care of a public authority because the child has lost its parents or because the authority has been given power to take the child from the normal parents by court order. In that case should the public authority have the right to pronounce on a question of sterilisation vis-à-vis the judgment of the doctor or doctors?
Thirdly, there is the jealously guarded principle of the clinical freedom of the individual doctor to decide what he judges to be the best interests of his patient.
Fourthly, if society permits or allows to go by default sterilisation in the case of one form of abnormality, what about other diseases or other forms of abnormality, such an spinabifida, mongolism and so on? Where is the boundary to be drawn and who should be permitted to draw it?
My own inclination—this is a personal opinion—is that the sterilisation of a child under age 16 should be prohibited by law and that it might be convenient that a provision to this effect should be incorporated in the Children Bill which is now before Parliament. That would be a possible way of accomplishing the legal prohibition if the House felt that this was necessary——
§ Mr. Deputy Speaker (Mr. George Thomas)
Order. I would remind the hon. Gentleman that he is not permitted in an Adjournment debate to seek legislation.
§ Mr. Hooley
I am grateful to you, Mr. Deputy Speaker, for bringing that fact to my attention. In making my 633 remarks I was in no way calling in question the good faith of doctors who in certain cases may believe that sterilisation is necessary, nor am I in any way questioning their professional integrity. But I base my proposition first on the basic human rights of the individual child and, secondly, on my faith in the advancement of medical and natural science to solve problems of this kind in a scientific way without exposing children to damage or danger which might inadvertently be caused if sterilisation were permitted without any adequate safeguard.
§ 12.13 a.m.
§ The Minister of State, Department of Health and Social Security (Dr. David Owen)
I am grateful to my hon. Friend the Member for Sheffield, Heeley (Mr. Hooley) for raising the wider question of sterilisation of a child under 16. He is naturally concerned about the particular case of the girl of 11 in Sheffield about whom so much concern has been expressed. As he knows, an application has been made for her to become a ward of court and that matter will be considered on 8th July by Mrs. Justice Heilbron. It would not serve the interests of that hearing—although I am in no way trying to say that the matter is sub judice—if I were to go into that case in great detail at this moment. That may be a matter for another time.
It is interesting how the ward of court procedure has been used in this case. Any person, including a body corporate or public corporation, may make an application under the rules of court to make a minor a ward of court. The officers of the court will usually satisfy themselves that such a person has a proper duty to or interest in the minor as to warrant the making of such an application. That application has the effect that the minor becomes a ward of court immediately, but if no further steps are taken in the matter that application and that status of the minor lapse after 21 days. If, however, the appropriate further steps are taken within that period, the minor remains a ward of court until such time as a registrar or judge has had the opportunity to consider the matter in the light of all the available evidence and to make some permanent order in the matter.
634 In certain circumstances the minor is the proper defendant to the application but, being a minor, cannot represent himself and, where there is a parental dispute or there may be no parents, is in any case unlikely to have the means to enable him to do so. In those circumstances the Official Solicitor is invited to act as guardian of the minor for the purposes of the application and the hearing, and if he accepts nobody in those circumstances would suggest that the interests of the minor would not be more than adequately looked after.
The procedure used in this case is a method of trying to ensure that some way can be found for the hearing of possibly an alternative case as representing the best interests of the minor.
I share the great anxiety expressed by my hon. Friend—an anxiety which has been widely expressed—about the sterilisation of children. It raises profound moral and ethical issues to which there are no easy answers.
My hon. Friend said he felt that such a thing should be prohibited by law. It would make it easier if I were able to tell him and the House that there were no grounds for carrying out the procedure on a young child of, say, 15 or younger. But I am advised that I cannot.
There are what I would call "no argument cases" where sterilisation would be necessary. The treatment for a cancerous growth of the pelvis requiring pelvic clearance will inevitably include the sterilisation of the girl. A cancerous growth of the genital organs of a boy will require equally drastic treatment. Though rare, it can affect youngsters of this age group.
There are more controversial situations, such as the pregnant child of normal intelligence. It is a sad reflection on our society that several thousand children under 16 become pregnant every year. There will very occasionally be among them a girl for whom the completion of a pregnancy at any stage of her life would carry grave risks for her health or even the risk of death. For such a girl, termination of pregnancy would be justified in law, and the girl might be advised to be sterilised at the same time.
635 There will also be again very occasionally a girl whose family is subject to a severe genetic condition, and who might not wish to bear a child which could eventually suffer from that condition The arguments for sterilisation in such a case will have to be balanced, but they may be very strong. But it is not possible, I believe, to lay down hard and fast rules. Each case must be looked at on its own facts and the facts considered bearing in mind what is known about the illness at the present time and the state of genetics. What is thought today to be fatal or incurable may not always be so.
There is always the risk that a child who is sterilised when her pregnancy is terminated may come to regret her decision. I am assuming that, where the child is of normal intelligence, a decision of this importance would never be made without her consent after the position had been explained to her in detail. To act otherwise would be hard to defend if the child were 15 or 16, and we are increasingly coming to a situation where a child is often asked about these things and is consulted.
There is another category—the vulnerable girl who has reached puberty. There are also a number of girls who are mentally subnormal and sexually vulnerable. If there are indications of hereditary abnormalities in her family, and if she is unable or unwilling to use an IUD or oral contraceptive, in such a case, it is possible to consider whether sterilisation would be in her best interests because of the problem of obtaining her consent in the full sense of that term. The consideration can become urgent if the girl is already pregnant and termination is contemplated, but I readily accept that these cases are much more arguable.
We ought not to think of this problem wholly in terms of girls. I mentioned the possibility of cancer in boys. The statistical information seems to suggest that there have been some vasectomy operations on boys under 16.
What I think is necessary—and this case in my hon. Friend's constituency has raised it very considerably—is that we should know more facts. The statistics on sterilisation are not comprehensive, but what is available has been collected from 636 regional health authorities. We have already been told that in one region the sterilisations carried out on children under 16 were, for 1973, one boy and no girls, and for 1974 three boys and no girls. Another region has reported none in either year of either sex. Figures from only two of the 14 regions cannot be given any statistical significance for the country as a whole, but I shall be looking into this.
We are also examining the Hospital Activity Analysis (In Patients). We are trying to break down from that which cases would come under the classification of sterilisation. However, these figures include those cases in which sterilisation resulted from the operation of hysterectomy which may have been performed at the time of the abortion as a life-saving procedure. It means that the statistical base from which to disseminate this information is not very full.
Having done this, we then have to question some of the issues which my hon. Friend raised. I shall not go into matters involving legislation. Indeed, I should be out of order if I were to do so. But there is a Select Committee of this House which at the moment is reviewing the medical termination of pregnancy. It may be more appropriate to consider this matter when that Committee makes its proposals.
This case has highlighted the fact that there is no obligation for more than one doctor to be involved in the decision, whereas we make it an obligation in a termination of pregnancy that two doctors are involved. In my judgment, it would be most unwise for one doctor to make such a decision.
My hon. Friend referred to the more difficult problem, especially when taking into account social grounds in making a decision, about the consultation of other professional bodies. We have to recognise that, in a much more interdependent decision making process which generally health care has become, there is a need to involve other professions. The final responsibility will always have to rest with the medical profession, but the medical profession is not alone in making that sort of judgment.
I have already indicated to my hon. Friend that there is a lot to be said for adopting the case conference approach in 637 procedures of this kind, bringing in all the relevant professional opinions. At times, they would be educational, psychological and psychiatric specialities. At other times, it would be a geneticist or a specialist in cancer. I am sure that the House would feel that the decision to sterilise a child was of such moment that it should not be made without all the available information from as wide and from as specialised an information base as we could possibly establish.
Although these are rare cases, they raise such profound issues that we ought to ask ourselves whether we should consider a code of practice. It may be that the professions concerned would welcome such a code. It is not an easy situation for a doctor to find himself having to make such a decision, often in a blaze of publicity.
Then we have to ask ourselves whether a code of practice, if adopted, should be reinforced by law and whether there are legislative safeguards that we should invoke. In effect, we are seeing in this case the invocation of an existing legislative procedure. It is the ward of court procedure. But is there some ground for having further legal safeguards?
However, I must tell my hon. Friend that I think that it would be very difficult to lay down any strict criteria which would have a universal application. Each case will be different. Each case will involve different considerations. But what has come out of this one case has made me convinced that we should now look at this issue. I undertake to my hon. Friend to look at this, taking account of all the professional opinion available to me, and to inform him and the House of the conclusions that we reach. It may take a few months to do. We shall not have the statistical information for some time, and I should welcome the views of my hon. Friend and of the professional bodies on the subject.
638 There is a need for further thought about this issue. As I say, the one thing that I cannot promise now—and I hope that I have convinced my hon. Friend that it would be wrong to do so—is to prohibit sterilisation by law. Regrettably, there will be circumstances when the sterilisation of a child under the age of 16 will be necessary. What we have a duty to do is to ensure that those decisions, when they are made, are made in a manner which will be acceptable to public opinion as a whole.
That is not to say we should challenge the right of doctors to make their own clinical judgment, but we should ask them to see that their clinical judgment is part of an overall professional judgment and to weigh the opinions of others when they form their view in many of these cases.
I have not mentioned the views of the parents. That is a sine qua non. It would be impossible to conduct such an operation without the agreement of the parents, other than in the most exceptional circumstances. In the whole question of legislation and attitudes towards children, we know that we cannot always assume that the views of the parents are necessarily in the best interests of the child. They are in the vast majority of cases, but there are times when the public duty and our social duty is to ensure that the interests of the child are given a fair hearing—and that may not always come only by listening to the views of the professions or the parents.
In that spirit, I should like to assure my hon. Friend that I am taking this issue very seriously and looking at it deeply. I hope to reach some conclusions in the next few months.
§ Question put and agreed to.
§ Adjourned accordingly at twenty-nine minutes to One o'clock.