§ 3.32 p.m.
§ LORD AMULREE
My Lords, I beg to move that this Bill be now read a second time. This is a short Bill which amends the National Health Service (Family Planning) Act of 1967 and I think it will be found that it constitutes another small step in the direction of forming a comprehensive family planning service within the National Health Service.
For those who wish to plan their families, there are, so far as I can see, three courses open to them. The first is continence, and I do not propose to go into that further now; the second is by means of contraceptive devices and the third is by sterilisation. The third is largely done on women and it is a major operation which carries with it a certain mortality. I should like to add to the possibilities that of male sterilisation—vasectomy, as it is called. This is not the castration of a man: it has no effect upon his virility and it has no effect upon his capacity for and desire for sexual relations. It merely means that he will become sterile. It is a comparatively simple operation to perform; it is done under a local anæsthetic, and the operation consists in cutting the duct called the vas deferens, by which the sperm gets from the testicle, where it is made, to the penis at the time of ejaculation when the sexual act takes place. There is little morbidity and no mortality at present, although of course this is a surgical operation and one must always remember that there is no surgical operation which has not some potential mortality. And it is 100 per cent. effective. The operation takes about 10 minutes, and some of the men can go back to work on the same day, though others may need to be off work for a day or two. There is some superficial bruising, but that is about all the ill-effects.
The 1967 Act does not empower the local authority to provide vasectomy services, or to support them financially as it can other forms of birth control. This Bill, if it becomes an Act, will permit the local authorities to provide such a service as part of the contraceptive services provided under the Act. It has 583 always been possible to perform vasectomy under the National Health Service for medical reasons, but I think the number of such operations carried out is comparatively small. I read the other day, however, of one general practitioner who is one in a partnership of five, who performs about 100 vasectomies a year in his practice under the National Health Service.
Circular No. 36/71 from the Department of Health and Social Security encourages local authorities to establish family planning clinics in hospital premises. I think, too, that one can say that the surgeons who will be called upon to carry out this comparatively simple operation can quite properly undertake to do this work, because it certainly constitutes a form of preventive medicine, even if it is carried out for the same sociological reasons as appear in the Abortion Act, where one of the reasons given for allowing an abortion to be performed is that the effect on the mother of having more children would have a bad effect upon the children of the family already existing. I was reading to-day about a case which seemed to show this very well. It was the case of a mother in her mid-thirties who had been pregnant five times; three of her children had died and one was grossly deformed. She had tried taking the pill, but it made her unwell and her life was being ruined by a fear of unwanted pregnancy. Her general practitioner arranged for a vasectomy to be performed upon her husband, with his consent, and the result has been a great improvement in her health and probably a much better life in front of it for the single remaining child of the marriage.
The Family Planning Association has 17 vasectomy clinics and about 3,000 of these operations were carried out during the first nine months of 1971. Many other towns have many such operations done. For example, in Cardiff 4,500 vasecomies were done last year, and even now there is a waiting list there of 4,000. I know one nursing home which is supposed to specialise in vasectomy, but I think most of their beds are occupied by abortions at the present time. If the vasectomy operation has to be done privately it costs from about £20 to £25. Reports have come in from Canada where 584 the operation is quite popular, and there they have had good results.
There is another report, from the Simon Trust, which deals with a thousand men who have been subjected to vasectomy, most of them between the ages of 30 and 45. None was over the age of 60, so there can be no suggestion that this operation is being done for rejuvenation, as was the case (some of your Lordships may be old enough to remember) when a man called Steinach performed this operation before the First World War in the hope that it would rejuvenate elderly men. I do not think that that fact comes into the matter now.
With regard to the cause of the men coming to this operation, in about 80 per cent. of the cases they did not like the contraceptive routine, and also about 50 per cent. of them had tried contraception and found that, for some reason or another, it did not work. About half of them, too, wished to spare their wives further pregnancies or the quite major operation of sterilisation. The results have been satisfactory. In a certain number of patients their health, they say, has been improved, and they feel much more comfortable and relaxed in their family relationship. In only under one per cent. of patients has there been some adverse effect, and nearly 100 per cent. of those who have undergone vasectomies have no regrets that the operation was performed.
There is no legal objection to this operation. It was thought that it might come under the Offences Against the Person Act 1861. It does not come under the mediaeval law of mayhem, about which we have heard something from time to time. One of the important matters is that there is need for the written consent of both partners, and that there must be no coercion of one partner by another. The marriage must be a good and stable one, and preferably there should be a certain number of children—I am not going to say how many, because that depends on the couple. There has to be sound advice and counselling given from the family planning people to ensure that the wrong kind of people do not get involved. Certainly bachelors should not be encouraged to take advantage of any scheme promoted by the local authority. What they do privately is another matter which I cannot go into now.
Are there any dangers? According to the Medical Research Council there 585 are really none, with the following two provisions: one, that the uninformed comments of a man's colleagues may lead him to doubts about his own virility. That is a question on which nonsense is bound to be spoken, and if people believe the nonsense they are told there is very little we can do about it. This is not an operation for unhappy or unstable marriages, because if it is done then both the partners will blame the operation for any subsequent misfortunes. One study has indeed shown that 10 out of 82 men had physical or psychological problems after the operation, but most of them had a history of such troubles before they were operated on. The advantage that the operation has over abortions is that abortions can have quite a substantial psychological effect on people; they also have a certain morbidity. It is not a very big morbidity, it is not a very serious one; but a certain number of women have some kind of fever after an abortion, and a certain number have some haemorrhage. I think that is all I want to say leading up to the provisions of the Bill.
The Bill itself is a very simple one. Clause 1 provides for the provision of vasectomy services under the contraceptive services. Clause 2 says that there shall be a report made from the local health authority to the Secretary of State categorising such persons by age, showing the amount of money spent, and that for the first two years the local health authority shall keep a record of people under 30 years of age applying for this treatment. Clause 3 deals with the financial side.
I do not want to keep your Lordships any longer. We had a long debate last week on population policy, and so I have not gone into this question at all. I hope, therefore, that your Lordships will give the Bill a Second Reading to-day. I beg to move.
§ Moved, That the Bill be now read 2a.—(Lord Amulree.)
§ 3.45 p.m.
§ BARONESS SEROTA
My Lords, I rise only briefly from this Bench to explain that the attitude of the official Opposition to this short Bill is one of complete neutrality since it involves highly sensitive moral and personal issues that 586 must surely be left to the conscience and decision of each individual Member of your Lordships' House. I myself welcome and support the Bill as a useful addition to the existing provision for voluntary vasectomy in National Health Service hospitals, where such operations are now being carried out at the rate of some 2,000 a year. Since, however, we know that the hospital service is not meeting the full extent of the demand, the permissive power that this Bill would give to local authorities should provide a useful extension to the range of other contraception services which they already offer and support under the National Health Service (Family Planning) Act 1967. I doubt whether it will make a major contribution to the problem of unwanted pregnancies, but it could be valuable in certain circumstances.
I should make it clear that my support for this measure is completely conditional on its firm commitment to the voluntary principle, making vasectomy available for contraceptive or therapeutic purposes only, as I would be implacably opposed to the use of vasectomy for eugenic or punitive purposes. This principle is clearly embodied in the Preamble to and in paragraphs (a) and (b) of Clause 1 of the Bill. Like the noble Lord, Lord Amulree, I agree that it will be essential to ensure in practice that those considering this course of action when their families are as large as husband and wife want are made fully aware that this is a completely voluntary and free choice, which only they themselves can determine in the light of the full consideration of all the facts of their own personal and family situation. This is already the established practice where vasectomies are carried out in National Health Service hospitals, and also in the vasectomy clinics established by the Family Planning Association in recent years, to which the noble Lord referred. These clinics are providing a most valuable service of high quality supported by appropriate professional counselling to those considering this method of birth control. I also welcome the provision in Clause 2 of the Bill, which will ensure that the records will be kept and reports made on the operation of the legislation.
This Bill has been very fully debated and carefully examined in another place 587 and it comes to us with broad based support in a form which I hope we can consider and agree before the time of this House is completely overwhelmed with the mass of Government legislation which is shortly to descend on us. I wish it a safe and easy passage. I give my support to the noble Lord, Lord Amulree, for this purpose, and congratulate him on bringing, it before us with his usual care, moderation and brevity.
§ 3.48 p.m.
§ THE MINISTER OF STATE, DEPARTMENT OF HEALTH AND SOCIAL SECURITY (LORD ABERDARE)
My Lords, I, too, would like to join with the noble Baroness opposite in congratulating the noble Lord, Lord Amulree, for introducing this Bill most carefully, clearly and succinctly. Perhaps I could try as briefly as the two previous speakers to indicate the Government's view on it. The main statutory responsibility for family planning services falls on the local health authorities under the National Heath Service (Family Planning) Act 1967, which this Bill seeks to amend. Local authorities may provide contraceptive advice and supplies when these are required, not only for medical reasons but also for social reasons. Some authorities provide these services directly and others make use of the facilities provided by voluntary organisations, but, whatever the system, the trend over the country as a whole is now one of rapid expansion, albeit from a small beginning. Local authorities have many other important responsibilities, and of course they have problems of priorities as between different services, for each of which there is considerable public demand.
I indicated in a necessarily rather brief speech at the end of last Wednesday's interesting debate the progress which local authorities are now making in the family planning field. I do not wish to repeat all I said then, but it may be helpful if I repeat some of the salient facts. Over the two year period ending next March, local authorities intend to treble their expenditure on contraceptive services to £2½ million per annum, and within that increase to raise the level of expenditure on domiciliary services fivefold. To give added impetus to these welcome developments, the Government have approved local authority schemes 588 a value of £170,000 under the urban programme, and announced extra grants to the Family Planning Association amounting to over £100,000. The Government have also encouraged the extension of family planning services by hospitals; and general practitioners are already a source of advice and supplies for a considerable number of people.
From what was said in this House last Wednesday, I know that some noble Lords believe that very much more needs to be done, but I hope it will be agreed that, in general, local authorities are now responding with much more vigour to the need for contraceptive facilities. There is, however, a gap in the services which local authorities may provide and this is the subject of the Bill which is now before us. Vasectomy may be undertaken in National Health Service hospitals where it is in the interests of the health of either the man or his wife, but the number of operations which can be performed in hospitals is limited by the resources available. Where vasectomy is sought for non-medical reasons, it has to be performed under the normal arrangements for private treatment.
There is no doubt that vasectomy is an efficient form of contraception, as the noble Lord, Lord Amulree, said, although it differs from other forms of contraception in that it can be undertaken only on the understanding that it is not reversible. It is therefore only suitable for those who have completed their families, and it is important that prospective patients should fully understand the implications of the operation. I very much agree with the noble Baroness, Lady Serota, who made the important point that it must be a voluntary undertaking. It is also important that, so far as possible, any patients for whom vasectomy would be contraindicated should be identified at the screening stage. Because these are professional matters, and because of the importance that has been attached to them, the Chief Medical Officer has convened an ad hoc group of professional people interested in the subject. They will assist him in formulating advice which can be issued, if this Bill is passed, to medical officers of health on the form of counselling which patients should receive before and after a vasectomy operation, to ensure that the operation is 589 performed only on those who really stand to benefit from it.
When the National Health Service is reorganised in 1974, the responsibility for family planning services will fall upon the new National Health Service authorities; and, as I said last Wednesday, the whole question of family planning is at present under review by my right honourable friend the Secretary of State for Social Services. I cannot anticipate the outcome, but I can say that, whatever conclusions are reached, the organisational change which will take place in 1974 will make it easier to arrange co-ordinated family planning services. In particular, in relation to vasectomy we should have the benefit of the reports which local authorities will give to the Secretary of State under this Bill during the next two years.
It seems unlikely that with the limited time and resources available to local authorities there will be a very large number of these operations paid for or arranged by them. But I know that some local authorities have felt the need for the powers which this Bill would confer, particularly in cases of acute social need where other methods of family planning have failed. It is the Government's view that although, normally, the hospital would be the sensible place for a surgical operation, the proposed legislation would fill a need which local authorities have felt and would therefore be seen by them as a logical extension of their existing powers.
The Bill incorporates requirements which will result in further information being available to Parliament over the next two years, although we shall want to study Clause 2 rather carefully before we come to the Committee stage and may have some Amendments to suggest to the House. The Government have given undertakings in another place that in addition to the professional guidance which I have mentioned there will be an administrative circular to local authorities conveying our view that the operation should be seen as suitable only for married men (or those with stable unions) who have completed their families. I am sure that local authorities can be relied upon not to use these new powers irresponsibly; and if your Lordships should wish to see this Bill passed 590 the Government would not wish to offer any objections.
§ 3.56 p.m.
§ LORD BROCK
My Lords, I find myself in something of a dilemma over this Bill. Certain of my friends, noble and otherwise, have asked me whether I agree with it and whether I shall support it. That is a question which I find it not possible to answer by a straight Yes or No. It is an example of the hoary old question, "Have you stopped beating your wife?". I was somewhat taken aback when I was asked whether, as a surgeon and because it is based on an operation, I would act as the sponsor of this Bill.
It is because I am a surgeon that I am unable to commend the Bill for two reasons. The object of it, we are informed, is to allow the operation of vasectomy to be paid for by the National Health Service via the local authorities. That is the essential. It seeks permission to spend money. In four years' time the matter passes from the local authorities and comes entirely under the control of the National Health Service. But this is much more than a simple enabling or amending Bill. It adds an operation to what is available under the original Act. I would remind your Lordships that it is a good thing that it is possible—and indeed proper—for this House to review and improve, or, at any rate, try to improve, Bills sent on by the other place.
My first criticism is in regard to the way in which surgery is dealt with in this Bill. I find it highly objectionable; it is mean and demeaning—perhaps not by intent, but, at any rate, as a result of lack of sensitivity and understanding of what is involved. Surgery—in this case the arrangements for doing an operation under the auspices of the local authorities—is dealt with, as your Lordships can see, in paragraphs (a), (b) and (c) of Clause 1 by the insertion of certain words and nothing else. In paragraph (c) there is an insertion after the words "substances or appliances supplied". It is not accorded the dignity of a separate clause or even a paragraph or sentence. It is lumped together with various contraceptive "substances or appliances"; it is joined with lubricant jellies, intrauterine devices, occlusive cervical caps 591 and condoms! This crude handling may not have been the intent—at least, I hope not. Perhaps I had better say no more about this, my first objection, except to comment that the way in which the proposal of introducing an operation into the list of substances and appliances to be supplied is, in itself, revealing in regard to the totally erroneous and shoddy way in which the use of surgery, of an operation, is advanced in this Bill. I suggest that it reveals an absence of understanding and it follows that it is my task and duty to try to correct this.
Vasectomy is an operation on the human body and would ordinarily be done by surgeons, and the result may well be that they will be expected to operate on large numbers of men for no medical reason or justification. I realise that various protestations have been made that the operation would be done only for medical reasons and in small numbers, but I am unconvinced. I have so far heard no suggestions that it should be done by other than surgeons—that is, by non-medicos—although this might provide an answer to the problem. I want to try to present to your Lordships what I think is the position of surgery in this matter, in contrast to the position of sociology. This is the substance of my second objection. I feel that a duty and responsibility falls upon me to present the surgeon's view, or what should be the surgeon's view, even though I am criticised for this. Many surgeons stand to be affected by this Bill and seem to have no one to speak for them.
The problem is two-fold. It is a sociological problem as well as a medical and surgical one. On sociological grounds I have no important objections to the Bill, and especially if it is the will of Parliament to accept it as a sociological measure. I have no objections if the operation is advised on strictly medical grounds, such as the case of a man who suffers from an hereditary transmissible disease. I can accept the somewhat more poorly defined category of medical reasons which are, nevertheless, recognisable. In general, these are related to the desirability of the wife not going through another pregnancy and when other methods of birth control are not fully acceptable. We must be realistic and realise that this operation will be requested and permitted for non-medical 592 reasons and on any man of any age, even though recommendations from the Department of Health may seek or advise a wider control. We have the example of the Abortion Act to indicate that the result will be vasectomy on demand. In this way it becomes a purely sociological step. I can recognise that certain great sociological advantages can spring from wholesale male sterilisation on demand and without cost when I consider it in relation to the problem of overpopulation, with which we are told that this country and the whole world is faced.
I should tell your Lordships that many doctors will not accept my presentation of the situation. I have been told that I live in an ivory tower, that medicine cannot be separated from social conditions, and that it is wrong to try to put medicine and social matters into separate compartments. To me, the subject is not made easier but more difficult by trying to mix medicine with other matters. At any rate, I am entitled to such a view. Moreover, I am no less likely to be right in my presentation of surgical ethics than someone who is not a surgeon. My position in the world of surgery entitles me to give my views even though some, who are not surgeons, may not agree with them. My interpretation of the ethics of surgery are; conventional and correct for to-day, even though some may say that they are not what will be thought to-morrow and that the ethics of to-day need changing. I repeat that these comments often proceed from people who are not surgeons and who do not have to do the operations they advocate so readily. These doctors are confusing medical ethics with their thoughts and decisions on sociological or some other grounds. I cannot see that I am less able to speak on behalf of surgeons than those who are not surgeons.
According to the Hippocratic Code, a surgeon should do an operation only for the good of his patient, to benefit him medically. There can be no ethical justification for a surgeon doing an operation on a human being for any other reason, including for the good of the State. Hitler's régime in the last war underlined this. One attempt at excusing surgeons to do this operation on demand—and we have seen this already to-day—is that it is only a small one. Its relatively small nature must colour our approach to it, 593 but this can create a false picture. I remind your Lordships of the young lady in Mr. Midshipman Easy who was going to be engaged as a wet-nurse. She was asked. "But that means you have had a baby yourself". She replied, "Yes, but it was only a small one".
I cannot see that the relative smallness of the operation justifies a surgeon changing his Hippocratic Code. It is a small operation, especially if done under a local anaesthetic. It has a certain amount of morbidity due to infection. I imagine it also carries the risk of psychological or even psychotic disturbances in certain types of patient. The mortality must be very low, but let us make no mistake: a mortality there must be in any effort undertaken by man. The risk of mortality increases when a general anaesthetic is used, and some patients will certainly demand this and some surgeons prefer it. I have recently heard a professor of surgery, who is already heavily involved in vasectomy, declare that general anaesthesia must have a place in this operation in distinction to local anaesthesia. This must increase the risk. Let us beware just because many doctors advocate this operation for non-medical reasons. They say that they are speaking as doctors, but I question this. They may be doctors speaking or writing, but they are in fact involved in a purely sociological matter. Their opinion is based on sociological, not medical, grounds. They should be clear about this, and not say they are speaking as doctors just because they feel strongly and sincerely about a non-medical matter.
At the risk of being thought vague, irresolute and reactionary, I must try to explain my reservations more fully to your Lordships. I hope your Lordships will agree that it is incumbent on a Member of your Lordships' House to try to present a detached, responsible view instead of just joining in the general crowd movement. I have pointed out that though this Bill seems to be essentially an enabling or amending Bill dealing with money in connection with a problem in sociology, it also contains a matter of fundamental importance to surgeons because it involves the doing of an operation. The situation seems to be not very different from the one which has arisen in the case of the trade unions. A recent 594 leading article in The Times commented that trade unions' power, like the power of business or policemen or even Government, must be a power controlled by law, and that no responsible Government will abolish this principle whatever changes may be made in the form of law. In this generalisation I would include the practice of medicine and surgery. These are, or should be, governed by the Hippocratic Code, and until we reject or change it this Code does not allow an operation to be done on a human being for a non-medical reason—certainly not for a sociological reason; and thus for the good of the State, and not for the individual.
It is suggested by some that the Hippocratic Code is obsolete and should be changed. Perhaps it should, but until it is changed we should honour it. It still stands as the law or code that doctors should follow. If it is wished to replace it by a new code more suitable to the 20th century, we could one day advocate a further change to a communistic code or to an authoritarian one such as caused so much trouble in the last war, when doctors were persuaded to do things they never should have done and for which they were tried as criminals. It has been suggested that operations can and should be done for sociological reasons. It is even stated that, as the rise in population is due to the successful progress of medicine and surgery, doctors should join in the task of controlling and arresting it as a social duty. I find it difficult to accept this suggestion as anything but monstrous. Perhaps I am wrong. Medicine would seem to fulfil its role when it has pointed out and has detailed the physiological and anatomical facts underlying procreation, and how they may be controlled, but we tread on very shaky ground when it is maintained that medicine and surgery should play a leading part in implementing a world-wide sociological need for population control. Is it really the function of medicine to have as its main activity the saving of life and also to conspire intensively in the suppression of life?
I think we have to consider the whole range of methods and devices to achieve family planning. Most of them are certainly non-surgical, and even non-medical. Their instruction and organisation is in general not inconsistent with 595 the medical ethic. But when we come to vasectomy, we come to a specific finite fact—an operation to achieve sterility. The implications of this require careful consideration, and certainly if it is to be done by a surgeon. I have attempted to sound a warning note against the easy passage of this Bill, which has been described as a mere enabling or amending Bill of no special importance. I have tried to explain how I feel it is my duty to indicate certain fundamentals.
I wish before concluding to make some comments on some factual details. Some of these arise from our experiences as a result of the Abortion Act, and again are related to what should be the position of the doctor, especially the surgeon, in relation to his own commitment. The Abortion Act contains a conscience clause—
§ LORD ROBBINS
My Lords, before the noble Lord proceeds to his factual detail, I wonder whether he would elucidate for me a distinction which seems to have been implicit in his observations hitherto; namely, the distinction between the function of the surgeon and the function of the physician. Would the noble Lord urge that it was illegitimate on the part of non-surgical medical research to inquire into the possibilities of restricting an increase of population which, if not restrained, it is fair to say, will certainly provide members of his profession with a far larger task than has hitherto been imposed upon them in the history of the human race?
§ LORD ABERDARE
My Lords, I hesitate to interrupt but I think we are being a little unfair on the noble Lord, Lord Brock, who is in the middle of his speech.
§ LORD BROCK
My Lords, I am not quite sure of Lord Robbin's point. He asked me whether someone other than a surgeon, such as a physician, should teach a surgeon what he could do to help a world problem of over-population—I am sorry, perhaps the noble Lord would put his question again.
§ LORD ROBBINS
My Lords, I am thinking of medical research in general applied to the question of the limitation by non-surgical means of an undue increase of population. I was asking whether there was a logical distinction between such operations and the operations contemplated in the Bill on the part of professional surgeons.
§ LORD BROCK
My Lords, I understand that the noble Lord, Lord Robbins, is asking whether there is any objection to non-surgical methods of limiting population. I have no objection at all: I am speaking purely for a method which involves an operation on the human body.
§ LORD PLATT
My Lords, may I put a question to the noble Lord? Does the noble Lord, Lord Brock, feel that physicians do not have any of these ethical principles?
§ LORD BROCK
My Lords, I am sure that the physicians have equal ethical principles, and I hope that they follow them as closely as surgeons like to do.
My Lords, I want to comment on some factual details. Some of these arise from my experience as a result of the Abortion Act and again are related to what should be the position of the doctor, especially the surgeon, in relation to his own commitments. The Abortion Act contains a conscience clause, presumably based on religious or moral grounds, but there is no specific recognition of the Hippocratic code; and, unhappily, many doctors, and certainly medical appointment committees, have ignored the ethical position of the doctor and the surgeon.
There will always be a proportion of surgeons who will be willing to do abortions or vasectomies because they genuinely feel that they should; some who are just disinterested and produce no objection and some, as we have seen, who are only too willing to do it for the money they get out of it. If this proportion of surgeons can fill the needs of the State and do all the necessary abortions or vasectomies, then there is no further problem. But this is not likely to be so. Pressure is then put upon other surgeons to do the work, and this is wrong.
If the Government want to get more vasectomies done than can be done by consenting surgeons, other surgeons 597 should not be pressurised into doing them. This is an iniquitous practice and is, unhappily, contributed to by doctors themselves, I like to think not through essential malignancy or perversity. We hear of this type of question being put to candidates for consultant posts when appearing before an appointment committee, "Will you be willing to take your share of the burden of abortions on demand?" In the case of applications for a gynaecological post, the question is, "What is your religion? Are you a Roman Catholic?" I suggest that this will be the danger with vasectomy. The question may be, "Will you be willing to take your share in doing vasectomies on demand with which we shall be faced?"
My Lords, I am disturbed, almost distressed, about the apparent absence of concern about who is to do the operations which will arise inevitably from this Bill. Little thought seems to have been given as to who is to do them and how they are to be done. Perhaps the administrative authorities have done so, but I doubt whether any of those actively sponsoring the Bill have faced, or even considered, the logistical problem. It seems to be taken for granted that surgeons will just do the operations out of their kindness of heart.
§ BARONESS BIRK
My Lords, may I put a question to the noble Lord, Lord Brock, in case he is not in the Chamber when we reach the end of the list of speakers? He mentioned the question of surgeons having the right to refuse to perform an operation, and that operations should not be referred to somebody else who might he forced to do them. I wonder whether the noble Lord will comment on the right of a patient.
§ LORD BROCK
My Lords, I have no objection at all to anybody doing any operation on a patient who has a right, medically or surgically. I am talking about a patient in regard to whom there is no medical or surgical reason to have an operation. Of course, I again emphasise that if a patient has a medical reason, or if there is a medical or surgical justification, the surgeon's duty is to help. Most surgeons already have more than enough to do in their routine N.H.S. work without taking on vasectomy ses 598 sions, and certainly not sessions with which they have no sympathy.
At a recent meeting in one of the committee rooms in this Palace of Westminster in which vasectomy was being discussed, a urological surgeon was asked about a vasectomy clinic clashing with routine N.H.S. work and thus adding to the already heavy commitments of pure clinical needs. The reply was that the vasectomies could be done at a special evening clinic and that he would be assisted by his registrar and residents. A more unsatisfactory reply I cannot imagine. He did not state whether his juniors would do this freely or whether they would just be expected to do it; nor whether they would have been asked if they were willing to "volunteer" when interviewed at the appointment committee. Your Lordships must all know of the long hours that junior hospital doctors already work and the resentment many of them already feel. Unless the Government can be sure of getting enough surgical facilities to do the indeterminate number of vasectomies on demand that will arise from this Bill, I suggest that they will have to recruit a class of surgical auxiliaries to do these soulless sessions of vasectomies. They are not a job for a professional surgeon and I presume that trained surgeons will not be directed by the authorities to do them against their will.
I am sorry, my Lords, if I have put problems in the way of the easy acceptance of this seemingly harmless enabling Bill. I feel that someone must point out that it contains deeper implications. I suspect that nothing I have said will have any effect on the passage of the Bill to-day, but at the Committee stage I shall propose an Amendment to remove the indignity to surgery of being classified with substances and appliances, and to add a conscience clause because some surgeons are going to need protection. Many surgeons already feel that they will need protection, and indeed may expect that this House will respect their feelings.
§ BARONESS SUMMERSKILL
My Lords, before the noble Lord, Lord Brock, sits down, may I ask him one question? In view of the fact that he objects to the sterilisation of a man on sociological grounds, does he equally object to the sterilisation of a woman who 599 has already had a large number of children?
§ LORD BROCK
My Lords, I am afraid that I have failed to make myself clear. I have said that I have no objection at all to doing an operation whether for male or female sterilisation when there are adequate medical or surgical-medical grounds. I also stated specifically that there is a rather less determinate group in which there are perfectly acceptable grounds, such as those mentioned by the noble Baroness; for example, a woman who for some specific reason should correctly be prevented from having more children. I am not suggesting that sterilisation should not be done; I am suggesting it should not be done for anything but medical or surgical reasons.
§ 4.18 p.m.
§ LORD GARDINER
My Lords, it is, of course, one of the functions of your Lordships' House to make clear that when we have a Private Member's Bill to consider all the possible objections to it receive due consideration. Until the noble Lord, Lord Brock, spoke, I was a little apprehensive that no such points might be raised, and I am sure that we are all grateful to him for having raised them. Speaking for myself, I feel that this Bill is a small but useful addition to the National Health Service (Family Planning) Act 1967. That Act did not involve the Government's doing anything for the purposes of the State; its provisions are purely permissive. It says that the local authorities may, with the permission of the Minister of Health "make arrangements for the giving of advice on contraception'', the supply of appliances and so forth. This Bill merely adds to that an additional form of contraception.
My Lords, one of the minor reasons why I welcome this Bill is that I have for some time thought that, as things now stand, far too much of the responsibility for the size of a family falls on the wife and much less on the man. Here is an opportunity for men to take their place. Of course, very few of these subjects are non-controversial. There was opposition to the Bill in the other place. By the Report stage, the opposition had fallen to three—which was really five, with the two Tellers; and on Third Reading, it had fallen to one; or three with the two Tellers. Generally, there is 600 no doubt throughout the country, as all national polls have recently shown, that about two-thirds of our people think that full contraceptive services ought to be available on the National Health Service. and free. Then (although I do not think my noble friend Lady Summerskill will necessarily agree with it) in a recent poll in a part of the country where there might be perhaps more opposition than elsewhere—namely, Liverpool and parts of the North-West—two-thirds were of the opinion that the pill ought to be on the National Health Service: 65 per cent. among supporters of the Labour Party and 67 per cent. among supporters of the Conservative Party. That shows how completely non-Party political this matter is.
The four objections to the Bill put forward in the other place, as stated by the leading opponents, were, first, that everything to do with contraception ought to be dealt with on an entirely personal and private basis, with which the State should have nothing to do at all. I imagine that those who hold that view must be very few to-day. The second objection was that no steps should be taken about our population problem so long as we were having immigrants coming into the country. Again, I should think that that view was held only by a small number of people. The third and fourth objections I can take together. One was that vasectomy would encourage licentious conduct, and the other was that it had not been sufficiently tested.
To take first the last point, between 1966 and 1970 the Simon Population Trust carried out 9,000 vasectomies; the Stopes Memorial Centre, 500; and the 17 vasectomy clinics of the Family Planning Association (in the nine months to September last), 3,000. So there has been a considerable body of information collected about this subject. I think that I should be wise probably to leave to the noble Lord, Lord Platt, and to my noble friend Lady Summerskill the point on medical ethics which was raised by the noble Lord, Lord Brock. There is no question of something being done compulsorily and still less of its being done for the good of the State. We are concerned with individuals; and I did not myself follow from what the noble Lord said why this is different from a woman I who has a plastic operation for purely 601 cosmetic reasons. I have never understood that to be contrary to the Hippocratic oath and I am not clear why it should be so here.
What are we really talking about my Lords? The Stopes Memorial Centre made a careful record of over 100 cases with which they had been concerned. The majority of the men concerned had four or more children. What we are concerned with is this. Let us take one case from among their papers. In 1969, an attractive immigrant had children by two girls in his village. In 1971, he had two more children by the same two girls. He then married. He has five children by his wife, so that he now has nine children; and I should say at once that, to his credit, he is supporting all nine children. Is he not entitled to say, "With nine children I think I have done my bit"? And are we really to say to him: "If only you were not supporting your nine children, you would have saved some money and would have been entitled to have a vasectomy done which you would have paid for; but now you cannot. Because you are supporting your nine children, you have no money, so the doors are barred to you." That is the sort of case we are dealing with.
§ LORD BROCK
My Lords, if I may take up the point that the noble and learned Lord has raised, this is an exact example of where a surgeon should not operate. I can understand the man's own wish to have the operation done. He has forced himself into such a position that it is desirable. But there can be no medical reason for doing this operation on him. I think that under our present ethics no surgeon would be justified in doing it. I am sure that he can get surgeons willing to accept money for doing it. I am not moved by the fact that he has no money left to pay for the operation.
§ LORD SEGAL
My Lords, if this particular man has been able to support the nine children himself, and very honourably, surely he can afford to get this operation done privately.
§ LORD GARDINER
My Lords, apparently he could not; and, since he supports nine children, I must say that I am not surprised.
602 As I have said, there is a great deal of experience in this field. The Simon Population Trust, for example (and here I have in mind any sequelæ there might be), kept a record for two years after the operation had been performed. It is always desirable to see how large is the return. They had 1,012 returns out of 1,092, so it was a 93 per cent. return. Looking to see what the general effect had been, both the man and the wife were asked the effect on their general health—whether there had been no change, whether it had improved or deteriorated. It is interesting to note that, of the men, 88 per cent. said that there had been no change; 11 per cent. said, "Improved" and 0.2 per cent. said, "Deteriorated". When it came to the wives and their health, 68.8 per cent. said, "No change", 31 per cent. said, "Improved", and 0.2 per cent. said, "Deteriorated". When they were both asked about the effect on their sexual lives the pattern was very much the same. The husbands' returns were: "No change", 25 per cent.; "Improved", 73 per cent.; "Deteriorated", 1.5 per cent. Of the wives: "No change", 20 per cent.; "Improved", 79.4 per cent.; "Deteriorated", 0.5 per cent.
My Lords, unless we are to leave our lives entirely in the hands of the doctors I should have thought that this was a sphere in which, with other forms of contraception, the individual was entitled to some help. We shall certainly carefully consider any Amendments which the noble Lord, Lord Brock, chooses to put down, but for myself I welcome the Bill. I think the provisions in it about the keeping of records are right and wise. I would agree that it ought not to take place unless all alternative methods of contraception have been fully discussed with both husband and wife, and unless the written consent of both of them is obtained. On the present footing, as I understand it, they should be told to regard the operation as irreversible. It may he that at some time experience will show that it is increasingly reversible; but I am sure that they ought to be advised of its irreversibility at the present time. With those observations I support the Second Reading of this Bill.
§ 4.29 p.m.
§ LORD CRAIGMYLE
My Lords, there seems to be a difference arising between 603 the attitude to this Bill of those like the noble and learned Lord, Lord Gardiner, and surgeons like Lord Brock. This tension leads me to fear that something which has not, I think, received much attention from the supporters of the Bill may be likely to occur when it becomes an Act in operation; namely, that there will be many people seeking the operation and an appreciable number of surgeons reluctant to do it: therefore, queues; therefore more people going to the private sector and quite likely falling into the hands of those who do not take quite such a strict view of the matter as was taken by the noble Lord, Lord Brock. However, this is a side point and was not one that I had intended to make. I should not have made it had I not been following those two interesting speeches.
My Lords, what worries me about this question—I was hoping that Lord Brock would turn his attention to it but he was on other equally important points—is that in the Bill it seems to me that the operation of vasectomy is being regarded in purely mechanical terms: you can justify making this slight change in the human body and everything will go on as before. I remember a few weeks ago, when we were in Scotland miles away from anyone who could call himself a mechanic—which I certainly am not—our washing machine was giving trouble. I rather hesitantly looked inside it, and I noticed that there was a broken part. I removed the broken part, realising that it was not very important, joined up the loose ends and the machine worked. That was a machine. But you cannot do that with the human body. Every part of the human body, as we now know much better than our fathers knew it, interacts on every other part, and all parts interact with fantastic intricacy upon the mind and therefore upon the personality. If this is true of every part of the body, surely it is more especially true of those parts of the body which have to do with the reproductive processes.
I cannot for one moment believe that if one severs the vas one is not going to induce perhaps in the very long term, say after ten years or so, certain changes in the personality. I cannot accept without sound evidence—and I have seen none so far—that what changes are thereby induced will be for the better. I fear 604 that the whole matter has been oversimplified. Insufficient is known, particularly about the long-term effects. Many of your Lordships will have read the proceedings in another place, and will recall that Mr. Abse quoted some interesting research and work that had been done in the United States. But these items of research are not yet a compendious volume of knowledge. We cannot really say that we know what are the effects of this operation on a man. We have, I think, probably a little more information on the psychological as well as the physical effects on a woman, because it is indicated on straightforward medical and surgical grounds far more than in vasectomy.
There is a danger of course that if one merely says, "It is a dreadful thing: you must not do this vasectomy because you do not know what the effects will be", this can build up into scaremongering. Or, indeed, another part of the same danger, it might be said, is that anyone who draws attention to that difficulty might be accused of scaremongering. I am sure that with carefully and discreetly worked research this danger could be avoided and overcome.
The operation of vasectomy, until we know from scientific research more about its results, must I think be considered in the simple old-fashioned terms which our forefathers would have used. It is quite simply a mutilation. The noble Lord, Lord Amulree, was at pains to distinguish it from castration. Fair enough. Obviously, castration is a crude and simple way of doing what? Doing precisely the same as you are trying to do by vasectomy. The operations are not all that different. Castration is crude; vasectomy sophisticated. But it is not really stretching language too far to say that it is a sophisticated form of castration.
§ LORD PLATT
My Lords, I do not think one can let that pass. It is, as the noble Baroness says, ridiculous. One removes sexual function, and the other does not. If sexual function is of no interest to the man, of course there is no difference.
§ LORD CRAIGMYLE
My Lords, I must confess that in my ignorance I have 605 always thought that the terms "sexual organs" and "reproductive organs" were more or less the same thing.
§ LORD CRAIGMYLE
Yes, I am: I am not unaware of what "vasectomy" means. It is all part of the same thing that the noble Lord, Lord Amulree, should speak about a man not losing his virility. To my mind, a man has lost his virility if he is not able to beget children. But I am very old-fashioned and very simple in these things. The human being is based upon a physical body, a piece of biology. However much one emphasises, as it is proper to emphasise, all the respects in which he transcends that body and is something rather more than a body, one must never allow oneself to forget that he has this biological base. This seems to me the difficulty when one completely takes away from sex the basic biological factor, which is the reproductive function of it. Therefore I fear that, although vasectomy will certainly ease the overt difficulties in married life, it will cause many men to have a blank somewhere in their hearts, the blank feeling: "I am no longer quite a man." Something will have been lost of the dignity of his man hood, which is so closely intertwined with the dignity of womanhood.
§ 4.35 p.m.
§ BARONESS GAITSKELL
My Lords, I wish to intervene quite briefly in support of Lord Amulree's amendment to the Family Planning Act. No one could have introduced the Bill with greater brevity or clarity than the noble Lord. The arguments in support of the Bill are simple, clear and straightforward. There is no moral issue involved for those who support and accept the desirability of birth control to-day. It is high time that men, too, took an active and responsible role in birth control. It is especially necessary to-day because of the noisy campaign against the Abortion Act; for those who shout and march against the Abortion Act are perhaps the most to blame for the increase in abortions. Your Lordships may think that that is not so; but indeed it is, because if these same people marched and shouted in a cam 606 paign to spread knowledge about all the safe contraceptive methods, the number of abortions would fall to a minimum and we should get to a point when abortion was resorted to only when medically necessary.
This weekend, on "The World at One", a Member of Parliament said that the Abortion Act enslaved women; it did not liberate them. I have never heard such poppycock. One has to smile when one hears men pontificating about the enslavement of women, having in mind the domination and enslavement of women by men throughout the ages. What greater enslavement of women can there be than repeated unplanned pregnancies? Perhaps some men regard an outsize family as an advertisement of their virility. I have a suspicion that the noble Lord, Lord Craigmyle, may take that view. At best, a large family may be the result of Careless rapture; at worst, just plain carelessness.
I am glad that men are supporting this Bill and I hope that male participation in birth control will grow. I hope that this will stimulate research leading to the male contraceptive pill. This Bill is a logical addition to the Family Planning Act. To-day we should do nothing to slow down the purposes of the Family Planning Act: we need to speed its implementation. I support this National Health Service (Family Planning) Amendment Bill, which is careful, sensible and logical.
§ 4.40 p.m.
THE LORD BISHOP OF EXETER
My Lords, I have no objection in principle and, so far as I know, the Church of England has no objection in principle to the use of vasectomy as a proper means of contraception. Indeed, I think that in the case of a mature married couple, who after taking everything into consideration come to the conclusion that their nest is full, a vasectomy supplies the cheapest, safest and most satisfactory form of contraception. Therefore to that extent I find myself fully in support of this Bill. But the Bill is very widely drawn. The noble Lord, Lord Amulree, spoke as though we could take it for granted that vasectomy would be granted only to mature people, married people or people enjoying a stable union. However, I can find nothing in the Bill which says this. I should be greatly reassured if I could
THE LORD BISHOP OF EXETER
My see that in fact the Bill does say this. But so far as I can see, all that the Bill says is that the Secretary of State will issue a document of advice to local authorities, which they will pass on to their medical officers. What I want to know is whether the advice given by the Secretary of State is mandatory or merely advisory, and whether the advice given by the local authorities to their medical officers is also mandatory or merely advisory. It seems to me that if it is merely advisory we shall be in grave danger of creating a situation similar to that created by the Abortion Act; namely, that in different parts of the country different rules and different practices will come to obtain. I doubt whether your Lordships or the Promoters of this Bill would really welcome that situation.
My Lords, to have a vasectomy is a very serious matter. It is a very serious decision to take and it ought therefore to be confined to people who are really mature. I think it would be disastrous for the country if young unmarried men were to be allowed to have this operation free on the National Health Service. I think this would be to withdraw yet one more restraint: upon promiscuity and to take one further step towards the demoralisation of society. Of course it may be that the State has, or will, come to the decision that the struggle to persuade the young to live in continence and chastity before marriage is a hopeless one and had better be discontinued. The Church has not come to that decision, and I hope it never will. We shall continue the battle to persuade the young to live in continence and chastity even though we know there will be failures, possibly many failures. Still, we hope that we shall be able to improve the 'general climate of opinion over the years which are to come.
Lastly, as the noble Lord, Lord Brock, has made plain, there are many people in the medical profession who would accept only with very great reluctance the burden placed upon them for deciding in any particular case what are the social needs—not the medical needs, for the medical profession is certainly perfectly competent and willing to decide those—and the social ethics of an operation. The medical profession rightly feels that it is no more qualified to make 608 decisions of that kind than anybody else. I think it is for Parliament to consider very carefully whether it is fair to impose this burden upon members of the medical profession. As we have heard from the noble Lord, Lord Brock, there are some who certainly do not want this burden placed upon them. They do not want the conscience of the community put into their charge and care. It is a matter for the community itself. Unless we can be quite clear, and the medical profession can be quite clear, what are the criteria of social need and ethics upon which a decision to accept or reject an application for vasectomy is based, we ought to hesitate for a very long time before passing this Bill.
§ 4.46 p.m.
§ BARONESS SUMMERSKILL
My Lords, I very much regret that the right reverend Prelate, as representing in this debate the Chuch of England, has adopted such a negative attitude. I listened to him very carefully. He dealt first of all with the manner in which the Bill might be abused by certain young men, and then he dealt with the social aspect that the medical profession might consider. Could he not possibly know what wonderful benefits this Bill may confer on the average family? Has that not entered into his thinking? As the only member of that Bench on this most important day—a day which will always be remembered in the world of medical sociology—he comes here and makes such a disappointing speech that once more one deplores the fact that he is speaking for the Church.
THE LORD BISHOP OF EXETER
My Lords, I hope the noble Baroness has not ignored the fact that I began my speech by saying that I thought that vasectomy was the best form of contraception for mature married people, and that therefore I recommend and support the Bill to that extent. Indeed, I presided over an inquiry—
§ BARONESS SUMMERSKILL
My Lords, is the right reverend Prelate asking a question?—because it is customary to ask a question and then of course the speaker continues.
§ BARONESS SUMMERSKILL
My Lords, may I say that this debate rather follows that of last week in your Lordships' House on population policy. I think that every speaker sought to make a constructive contribution and, so far with few exceptions, that has been the rule to-day. I feel that we should congratulate those in another place—particularly the young male Members—for the untiring manner in which they have raised the question of vasectomy, culminating in this Private Member's Bill. Indeed, there are indications that the young men of to-day are becoming more involved with the family than were their fathers before them. The long list of men waiting for a vasectomy can offer no better proof of the husband's desire to share the problems arising from the determination to avoid an unwanted child.
I have to remind the House that this has not always been the case. It is the woman who has to bear the burden of contraception and she has also to bear the subsequent pregnancy if no contraception is accepted. It is the woman, the whole time, who carries the burden of producing and rearing children, together with the agony—the physical agony—of being compelled to bear too many children and subsequently of course to lose her health and strength in middle and old age. Therefore, listening to the debate in another place, I greatly welcome the fact that contributions were made by some of the finest young men on the subject of this important advance in medical science. This I find very heartening. What is my criterion? I believe that the most important criterion to be applied to vasectomy is whether it is calculated to improve marital relationships and promote the welfare of the family. What I have to say will be related to that criterion.
Some men are uneasily aware of the potential dangers of the contraceptive pill. May I say in parenthesis that I taught contraception when I was a young woman doctor, and indeed during all my medical life. My only objection to the pill has been that innocent and ignorant women—little more than girls—have taken the pill without being aware of its potential dangers. We have not had sufficient experience yet to know whether or not the pill is safe. This has been my only objection to the pill as a contraceptive. 610 I know that many dutiful wives take the pill with fearful mental reservations. Twenty-five per cent. of these women suffer from depression. If the wife is depressed as a result of using a certain method of contraception, far from improving family life the pill could be an active agent in promoting marital disharmony. It would seem therefore that vasectomy could make an important contribution to the universal desire for responsible and wise parenthood. I believe to-day that that is a universal desire. I agree that this may have arisen because of propaganda in our newspapers telling us of the increasing population and relating this increased population to pollution.
Having listened to the noble Lord, Lord Brock—and I say this in all kindness—I think he will agree that in his opening remarks he was a little confused. The noble Lord is a confusing character; he is so positive in certain things and so negative in others that some of us do not know where we are with him. He said in his opening remarks that he objected to the form of administration; he also objected to being bracketed with contraceptives, and therefore what he was really saying, I would remind him, was that he was annoyed at being bracketed with some of the activities of the physicians. I would remind the noble Lord and the House that at the beginning of the year 60 eminent doctors sent a joint statement to the British Medical Journal and the Lancet emphasising the relationship between the growing population and the environment, and that there should be greater involvement in family planning, including vasectomy. These were 60 eminent men, a cross-section of the country. I am sure that the noble Lord, Lord Brock, is big enough to know that while he may hold these views there are large numbers of men, physicians and surgeons, who take a completely opposite point of view.
The Abortion Act has been mentioned It has provided an escape for the woman who is determined not to bear an unwanted child. But this is a drastic step and should not be regarded as an alternative to contraception. The fear of some of us is simply that there are those who say, "There is no need to promote contraception because the woman will get an abortion". I regard that as being rather cruel to the woman. Nevertheless, in no 611 circumstances would I subscribe to the hysterical outbursts by some elderly gentlemen in Trafalgar Square, I think it was, who denounced abortion. They were men who had had no experience of the field in which they were daring to make these rash statements. I asked the noble Lord, Lord Brock, if he objected on sociological grounds to a man being sterilised whether he would object to a woman being sterilised. I would remind him that it is quite remarkable how often a mother submits to the major operation of sterilisation while her husband, who has played an active part in her frequent impregnations, is left presumably ignorant of the fact that he could have saved her this further ordeal by undergoing the minor operation of vasectomy with no more discomfort than a tooth extraction.
The noble Lord opposite, who has a religious faith and therefore finds it difficult to pursue a rational argument in this matter, must also recognise that this operation will relieve countless women who have already produced large families, and have all the weight and responsibility of bringing them up, of great anxiety in the future. In considering contraception we should never lose sight of the fact that while pills can have serious side effects, the occlusive cap is not always occlusive. and the intra-uterine device can come out or have unpleasant health consequences. I would remind the House that we had some years ago (some of the older Members will remember) an intrauterine device called the Graffenberg ring. It was abandoned by responsible doctors many years ago because of its potential danger. I deplore the fact that these intra-uterine devices are being manufactured and thrust into ignorant women, particularly the ignorant, inarticulate, poor women in the East, who may not see doctors at all during the whole of their lives.
To-day we have a method of contraception which is harmless, painless and without any side-effects, a method which may relieve some of these unfortunate women. It is also 100 per cent. reliable. As has been said before, the operation takes only about 15 minutes under a local or general anæsthetic. Some of the figures of the Simon Population Trust have been mentioned. I should like to put them on record again. The 612 Simon Trust said that only two of the 1,012 men who had been sterilised reported that their health had deteriorated; and 115 of them claimed improvement in their health. Only fifty reported any deterioration in their sex life, while 740—almost three-quarters of the sample—reported that marital harmony had much improved. Under one per cent. reported less harmonious relations.
Again, one speaker referred to the psychological effect. There arc those who will say, "What psychological effect must this have on men!". My Lords, this Bill may be new to this House. but vasectomy and the effects of it have been considered by the medical profession for many years before anyone thought of framing a Bill and bringing it before Parliament. The whole question of any psychological effect has been considered by the best psychiatrists in the country. Therefore the House should be reassured by the support for the Bill which has come from the Royal College of Psychiatrists who, after the most careful examination, gave it their strong support.
Now I come to the point raised by the right reverend Prelate: the suggestion that the operation might be used by promiscuous young men. This can be discounted by the experience of those engaged in the work—and only those engaged in the work can give the answer to it. They see the man for the first time; they can sum him up. They ask for his age, his marital record, and so on. I do not know whether any of the men described by the right reverend Prelate ever had a vasectomy, but I can only read him a letter from somebody who devotes her life to this work. The letter was written by Dr. Pauline Jackson, of the Cardiff Family Planning Association clinic. She wrote:The men arc first and foremost family men concerned primarily with the welfare of their wives and children and one gets a tiny hut vivid picture of a deep and shared marital happiness and devotion.Finally (this is an aspect that I have sought to emphasise), it is the contribution to marital happiness and the consequent improvement in family life which has evoked so much powerful support for this Bill, and diminished the opposition. I hope that this House will reflect that commendable attitude.
§ LORD BROCK
My Lords, before the noble Baroness sits down, may I make one more attempt to clarify my views on this issue? It may perhaps save her the bother of reading Hansard to-morrow. I will quote from what I said. I can accept the somewhat more poorly defined category of medical reasons which are nevertheless recognisable. In general, these are related to the desirability of the wife's not going through another pregnancy and when other methods of birth control are not fully acceptable. l think there is no difference at all between us, in that if there are reasons for the wife's not going through another pregnancy then one would accept that as a medical reason for doing vasectomy.
BARONESS SUMMER SKILL
My Lords, I will certainly read the noble Lord's speech: he knows I always read his speeches. I am only sorry that to-day we found him in a minority of one.
§ 5.1 p.m.
LADY RUTHVEN or FREELAND
My Lords, I am very glad to support the noble Lord, Lord Amulree, in his moving of the Second Reading of this Bill. I feel rather diffident in addressing your Lordships on the subject, being a woman and an old widow, but I am speaking really because for the last twenty years I have been associated with the Family Planning Association and am a founder Vice-President of the Birth Control Campaign and a member of its Advisory Council. I very much hope that this amendment to the 1967 Act will he well received by your Lordships and that the House will support it. The Family Planning Association opened its first vasectomy clinic in 1968 and since then has performed 4,731 operations. It now has a waiting list of over 4,000. In providing vasectomy as a method of birth control, its experience is very much that which the noble Baroness, Lady Summerskill, said Dr. Pauline Jackson had expressed to her: it is requested nearly always by happily married couples—and I emphasise "couples". The woman has to agree as well as the man. It is mostly requested by happily married couples when they have completed their families, or in cases where the wife, due to such causes as thrombosis or high blood pressure, is unable to take the 614 pill or, for other reasons, to use any other form of contraception. Of these 4,731 operations by the Family Planning Association, 166 were performed without charge, and in some cases the cost was paid by the Margeret Pike Centre, a private charity associated with the Family Planning Association.
The amendment now before the House will permit the local authority to set up its own vasectomy clinic within the National Health Service, or to pay for the vasectomy operation to be performed by one of the existing 17 Family Planning Association clinics throughout the country, or in one of the other charitable clinics, such as the Simon Community, which have the facilities to perform the operation. From my experience in the Family Planning Association over twenty years, I am convinced, very much as is the noble Baroness, Lady Summerskill, that the burden of birth control almost always lies with the woman—and, I think, very unfairly for her. This amendment now before the House would enable the husband who wishes to do so to shoulder his responsibility, and I hope very much indeed that your Lordships will give a considered judgment on this amendment to the Act now before us.
§ 5.5 p.m.
§ LORD PLATT
My Lords, most of what I might have said has already been said. I have been President of the Family Planning Association and I am sure that all Members of your Lordships' House will know which side I am going to take in this debate. I shall not attempt to answer all the points raised in full; indeed, it is not my duty to do so. I would say to the noble Lord, Lord Craigmyle, once again, that we are not setting out to produce a new race of castrati, however great their services may have been to music and the Church in the 15th and 16th centuries. This is an operation of a totally different kind and I am afraid it will not produce those beautiful voices that we sometimes hear. The noble Lord did, however, along with the noble Lord, Lord Brock, refer to the possible change this operation might produce in the male. I can only say, in the first place, that statistics seem to show that there is a possibility of a change for the worse in—was it 0.2 per cent. of the cases? But I would say that there is a change for the worse in women on the 615 contraceptive pill in a very much higher percentage of cases. It alters a woman's personality; it alters her figure; it alters her physiology; nobody knows what the end results are going to be in the long term, and it is associated with a quite definite mortality—all of which seems to have been neglected by my noble colleague Lord Brock, who was keen to tell us that this was an operation and that therefore we could not keep mortality and dangers completely out of it—with which, of course, I agree.
The noble Lord, Lord Brock, seemed to be highly concerned with the dignity and ethical responsibilities of surgeons. He did not seem to concern himself with the ethical responsibilities of physicians, with whom I include general practitioners. Every time one prescribes a pill which has a really powerful action one is taking a risk. One has the same kind of responsibility as a surgeon has with an operation. Of course, if you take extreme cases, the prescription of a fairly harmless pill involves nothing like the responsibility of a major cardiac operation, such as the noble Lord, Lord Brock, has such a splendid reputation of being able to perform. Nevertheless, the physician nowadays, with powerful remedies such as exist, takes a very big responsibility for his patients when he prescribes the pill. If you take the view that a surgeon should not perform a vasectomy because he is not doing it in order to cure some disease or malformation, then you must face the situation that you are not going to use the contraceptive pill at all. If the objectors will face that situation and say, "Yes, this is what we mean. We mean that physicians, general practitioners and others should not prescribe the contraceptive pill", well, let them get up and say it. So far as I know, they did not say so.
There is, however, one essential difference. One must admit that the contraceptive pill can (provided that it has not killed a woman in the meantime, and death is rarely the case) be reversed. Although we are not yet quite sure of the effects of stopping the pill in a woman who has taken it for a good many years, nevertheless it is normally considered to be reversible, whereas vasectomy at the present time is considered to be reversible. I believe it was the noble Lord, Lord Aberdare—and I should like to 616 thank him and also the noble Lord. Lord Amulree; I meant to do so at the beginning of my speech—speaking not for the Government but at any rate from the Front Bench, who said that for the time being vasectomy was to be looked upon as an irreversible operation. I think that is the only fair thing to tell a patient. Nevertheless, I believe he also said that further research may throw up ways of making it a reversible operation.
§ LORD ABERDARE
My Lords, may I interrupt the noble Lord for one moment? I did not actually go so far as to say that I expected further research to make it reversible. I definitely said that the operation should be considered to be irreversible. May I also confirm to the noble Lord that I was speaking on behalf of the Government and not for myself.
§ LORD PLATT
My Lords, I am grateful to the noble Lord for putting me right on those points.
I am very disappointed that there is only one Bishop in the House on a matter which seems to me—indeed I believe it is to all of us, and certainly it is to many noble Lords—to be a matter of great ethical importance. But the right reverend Prelate made one remark which I thought I might comment on, and that was about throwing the burden on the medical profession. I would of course agree with him that we have no right to dictate to the State, to the public or to anyone what the ethical principles of life should be in this day and age; but as for imposing burdens on the medical profession, I think the medical profession exists to carry burdens. For that reason I would not agree with the noble Lord, Lord Brock, when he made a remark which I think your Lordships will find in Hansard to-morrow: that it was not a job for a trained surgeon, as if there was some kind of indignity in doing a minor operation although it is all right to do a major one. My Lords, I have done all kinds of minor, menial tasks for patients in my lifetime, and I have never regretted it.
§ LORD BROCK
My Lords, before the noble Lord sits down, I should like to defend myself. I merely stated that it is not the job of a professional surgeon to do an operation for which there is no justification on medical grounds. This 617 would apply whether the operation was small or large.
§ 5.14 p.m.
§ BARONESS BIRK
My Lords, I have much pleasure in supporting this Bill. It seems to me, having listened to the debate in this House, and also having read what was said in another place, that the fundamental question is whether one really believes that, so far as possible, people should be helped, both for personal reasons and in the interest of our population, in order to restrict their families as and when they want to do so. If one accepts this premise, then one must look at the whole range of contraceptives which are available; and this of course includes sterilisation, both for men and women.
A year or so ago, when I first heard about vasectomy, I was rather taken by surprise. I think the distinguished doctors who are present will agree that anything new—and this applies through the whole range of medicine—is at first received with doubt, anxiety and often scepticism. I do not disagree with that. However, I think by now we know enough about this particular operation, having heard from scientists and doctors about the operations which have been carried out, to accept that if the operation is carried out properly and if the counselling is correct, it is as safe as it can be. As has already been said by several speakers, the onus for contraception has up to now been laid mainly on the woman. In the P.E.P. broadsheet that came out in March, 1972, on Abortion and Contraception: a Study of Patients' Attitudes, one of the conclusions to which the authors reluctantly came was:There do appear to be powerful inhibitions against using contraception among women of all ages and statuses in our society.I believe that this alone means that one has to see contraception, as I think so many of us here do, as a dual responsibility. And although this Bill does not go the whole way—and I think most of us who are speaking for it would like to see contraception as an integral part of the National Health Service—it will help to bridge an urgent gap. It also accepts the principle that in this area what is contraceptive sauce for the goose should equally be so for the gander.
I do not want to get involved too deeply in the medical controversy between 618 the distinguished doctors who have spoken, but I am a little puzzled. In 1970, 44 per cent. of married women who had terminations were also sterilised, and I know, both from speaking to gynæcologists and from the evidence we received when I served as a member of the Working Party on the Unplanned Pregnancy set up by the Royal College of Obstetricians and Gynæcologists, that many gynæcologists were quite prepared to sterilise a woman after she had had a baby, after they had refused a termination. So the idea that women have not been sterilised for social reasons (I agree that it depends on how one defines the word "social") is, if I may say so with great respect to the noble Lord, Lord Brock, really rather a lot of nonsense. I should have thought—and here I speak for the women—that a combination of an abortion and sterilisation is a very unpleasant thing, both physically and traumatically, for any woman to undergo. From my reading and understanding of the vasectomy operation, it seems to be on a rather slighter and smaller level and also the results seem, fortunately, to be much more minimal.
The Health Education Council, of which I have the honour to be Chairman, had a contraceptive advertisement, which we have now produced as a leaflet, inserted in several popular papers for the month from the middle of February to the middle of March. This set out factually the different forms of contraception that were available. It referred to sterilisation and to "a surgical operation, known as vasectomy, for men". The advertisement then described the operation, but your Lordships will know about it. The advertisement—reprinted in a leaflet—now, as I say, explains the disadvantages, that the man cannot change his mind about having no more children. Then, under the heading, "Where can you get or buy it?", it says, "Your family doctor will advise".
I should like to put the mind of the right reverend Prelate at rest because, out of 500 letters received by us, over one-sixth—the highest number asking for information about any specific form of contraception—were letters from men (with one or two from their wives) asking about vasectomy. There was not one letter from a single man, except a man who was over sixty years of age, who had not had sexual intercourse and who, 619 our medical advisers said, needed medical help. Since these advertisements went into the popular newspapers: the Daily Mirror, the Sunday Mirror, the Sunday People, the Sun and the News of the World, one would have thought that if there were all these promiscuous bachelors who were going to get on to the sexual bandwagon, they would have written in, because they could have written in complete confidence. But we did not receive one letter of this sort. In fact, as has been confirmed this afternoon by some noble Lords, the letters were all from people who had thought it out, people who were desperately worried. They ranged from a husband of twenty-seven who has five children and who said:My wife and I have talked it over and find it is best for us. We find there is some—, thing against all the other methods.I must say that what my noble friend Lady Summerskill said is true: there are still a great many women who are concerned about the pill and who are moving, in effect, from it. In the future we hope this will not be so, but that is the situation at present, and that is what we are dealing with in this Bill. This correspondent went on to say:The doctor said he could not help. I would have to wait three years for N.H.S. or go private and pay approximately £30 to have it done in six weeks. The local F.P.A. could not help as their nearest clinic is at Cardiff and it is too far for me to go.According to the latest F.P.A. figures, which were put out on Friday, at their clinic in Cardiff there is a waiting list of 55 weeks. The ages of our correspondents ranged from about thirty to fifty years old. There was one case, not exactly typical. But more than one posed the same problem: a man of over forty; his wife forty; two children, fourteen and seventeen; the wife had had a miscarriage. They decided that one of them should be sterilised and they went to their family doctor. The man wrote:He has told us he cannot do anything as he is a Roman Catholic and his religion does not permit the operation at the present time.The wife then saw a specialist and asked whether her husband could be sterilised. The specialist said it was against his religion to make any such arrangements.
While I agree— and I think we all do— 620 that a doctor must be free to arrive at a decision of conscience and clinical judgment, I think it is also true, as I put it, perhaps not very clearly to the noble Lord, Lord Brock, that the patients also have a right to have something done, so long as it is legal and considered medically safe, for their own wellbeing and their own welfare. Here I would take very strong issue with the noble Lord over this question of wellbeing and good health. I think, if I may say so, that he is defining medical health on extremely narrow grounds. The whole wellbeing and health of a person must also depend on his or her mental and emotional health: social conditions and a number of other things come into it.
The Working Party on Unplanned Pregnancy recognised this point, for we said:For the doctor unwilling on grounds of conscience to refer a woman requesting termination there is an obligation to seek a different opinion ".This, I would say, is exactly the same principle that should apply to vasectomy; and this Bill, I believe, will make it that much easier not only for the patient but for the doctor who has these very strong feelings of conscience and conviction, because then he or she can refer the patient much more easily to a local authority health clinic. I hope this will mean that this will help to increase and enlarge the facilities. The noble Lord, Lord Aberdare, when he was winding up the debate on population said (he was so short of time I did not have the heart to interrupt him) that there were family planning facilities everywhere in the country except the Scilly Isles. I think it was through shortness of time that he forgot to add that the facilities vary tremendously, and that whereas only about a third can be termed anything like adequate, there are some in respect of which to pay lip service would be to use the lips in a very generous manner.
I would also say to the noble Lord, Lord Brock, that our Working Party, which had a distinguished Chairman, Sir John Peel, recommended that facilities for both male and female sterilisation should be provided within the N.H.S. The report also says:The Working Party is concerned that so few vasectomies are done within the National Health Service, although it recognises the difficulty that it requires the same degree of concern over social and family matters by surgeons 621 as already exists among obstetricians and gynæcologists".I do not want to get involved in internecine warfare, but it may be that the surgeons do not consider the gynæcologists surgeons. So far as I am concerned, they all call themselves Mr., so I take it that they are. But this raises a socially much wider point which cannot be confined within narrow medical limits. I believe that this Bill, although it goes only a small way towards a comprehensive contraception service, is an important one and is a big step forward. I think underlying so much that has been said is the need for a great deal of education both on this and on contraception generally. Incidentally, a great many of the letters to the Health Education Council threw up such human tragedies, such tremendous ignorance and such desperation in which so many people were living, that what really is needed is a far greater effort of publicity and education to motivate people towards contraception, in their own family interests and in the interests of society, if not only unwanted but unplanned pregnancies are to be reduced. This, in my opinion, is the highest priority at this time in any approach to a population policy.
§ 5.27 p.m.
§ LORD LEATHERLAND
My Lords, we have heard some very thoughtful speeches from some very eminent members of the medical and surgical professions. I think there was some lack of unanimity about them, and so it appears that the simple layman, such as I am, has to make up his own mind. I think I can safely say that I have no personal interest to declare. I had my 74th birthday a fortnight ago and I am looking forward joyfully to my Golden Wedding two months from to-day. But I am a supporter of this Bill. During recent years I have warmly supported various Bills on matrimonial subjects brought forward by my noble friend Lady Summerskill and other Members of this noble House. I have felt that the aim of those Bills was to improve the position of women in our modern society. I feel that this Bill has a similar aim, and so it has my warm support.
Nevertheless, I have some little apprehensions, some little doubts about the precise form in which the Bill is drawn. I must confess that I know very little 622 about women. I have read a good deal about them, and if there is one thing that emerges I think it is that they have a habit from time to time of changing their minds. In the operation of this Bill we may have a case of a woman who says, "Yes" and a little later she may be inclined to say, "No", but the irrevocable action has then been taken. Then we have to consider the sad occasion when one child in the family dies; the woman may be yearning for another child to take that other one's place, but she has to content herself with the fact that this final operation has taken place upon her husband. Then we may have the case where the wife dies. It need not necessarily be a case of death that has followed a long period of invalidism. We get sudden death these days with high speed motor cars and careless pedestrians; death may descend on any person suddenly at any moment. In that case the man may wish to marry again. But this surgical action will have been taken, and what is he to feel? Then there are cases where the divorce courts may have stepped in and a decree may have been granted.
In all these cases it seems to me that if the final decision has already been taken, then that man is going to be in a very embarrassing position. Women are going to think about him, "Well, there is something missing". I feel that while I enthusiastically agree with this Bill there ought, on the Committee stage, to be written into the clauses some provisions aiming at greater safety. I think we would want to know that the wife has really given her consent, not in a sudden emotional moment but as a result of really careful, mature thought. We do not want any impulsive decisions taken which might afterwards be regretted.
Those may be minor points; they may be matters upon which we can get an assurance on the Committee stage. It may be that the noble Lord, Lord Amulree, will be able to give us assurances now. It may very well be that he will be able to say that these exceptional points, if you like to call them that, will be covered by the memoranda that will be sent out by the Ministry to the local authorities. I am a little doubtful about what is to happen and the sadness that is likely to follow in the three or four kinds of exceptional case that I have mentioned. 623 However, I hope that I can be reassured on those points, and I certainly shall vote for the Second Reading.
§ 5.31 p.m.
My Lords, I owe a great debt of thanks to the noble Lord, Lord Leatherland. I put my name down at the Table to say a few words after the noble Baroness, but the noble Lord, Lord Leatherland, has said so much better than I could and so much more shortly some of the things that I thought ought to be said that what I have to say will be reduced from possibly five minutes, to, I hope, not more than two. It is to emphasise a point which has been put by a minority in this debate: that the principle in this Bill, unlike the principle of the Abortion Bill, is one which no honourable man, so far as I can see, can object to. Unfortunately a Bill can have intentions as honourable as the Order of the Bath with St. Michael and St. George thrown in (or ritually immersed), and still be a disastrous Bill, if it is not carried out as it is intended to be but only as people believe it to be drafted.
This seems to me essentially a Bill in which the drafting is of vital importance. The safeguards which have been promised are an intrinsic part of the Bill. I know that I am not allowed to quote from anyone in another place who is not a Minister, but may I paraphrase only two points made by the proposer of this Bill? He told us that he was satisfied that the assurances he had received in Committee, in which several Amendments were accepted, would be adequate but some would need further consideration in "another place". They will receive that. After the debate we have heard to-day we are in a much better position to consider what those points will be. I need not elaborate on that at all except as a warning that if there is an Amendment I may have something to say on it.
The second point, to make it very shortly, is that he said that he was happy that, by the Departmental circulars and the Working Party which will be set up to advise his Department, a "more adequate guarantee" has been given that all possible complexity will be fully advised upon and met. That is setting a high standard for this House. I do not think we want a more adequate guarantee; we 624 want an adequate guarantee. But we do not want a less adequate guarantee; and, speaking purely from personal experience of the Abortion Bill, we do not need a more or less "adequate guarantee; we want as good a guarantee as we can get that the Bill means what it says and that we agree to it.
The last point I will certainly not dwell on, but it was suggested by the noble Baroness, Lady Gaitskell, that those people who take part in marches and shout about abortion do more harm than any others. I am afraid that might have been directed at me, in that I did take part in a march yesterday in Liverpool, in which we marched, but did not shout, it was a march for which I was partly responsible because a society of which I have the great honour, undeservedly, to be Chairman had organised it. We had expected perhaps 10,000 or 15.000 supporters, and in fact we received what The Times called 40,000, the police called 65.000, and another newspaper called 100,000, supporters; but there was no shouting by the marchers. The shouting was done entirely by "members" of three organisations, who I am sorry to say are mentioned with gratitude by the proponent of the Bill. They were not of course members of the organisations, but they were young men who claimed to be members of the conservation society called Friends of the Earth, who, with rubber balloons under their pullovers, rather obtrusively thrust advertisements for contraceptives at nuns and nurses, who they seemed to think were the same, arid also at myself, on the ground that I happened at one time to be marching next to the Anglican Bishop of Warrington, who was wearing a scarlet cassock and was therefore thought to be a representative of the Vatican. They were requested by the police to desist, but they did a good deal of shouting. I only say this to defend myself from the noble Baroness sitting behind me.
As to the Family Planning Commission, which she, by a rather delightful Freudian error in Hansard the other day referred to as a "Family Panning Commission" (one will find that in Hansard, but she did not mean it)—that is an admirable society, but we do not want anybody to be attached to it who has not the same intentions as Sir John Peel and all its genuine members, such as the noble 625 Baroness. All I am trying to say is that we want to look at the actual application of this Bill more carefully than we looked into that of the Abortion Bill, in order to avoid what I would regard as a tragedy almost as great. It would not be as great, because I think for a man to lose his virility is not as bad as for a man to kill a child. Those are my opinions. That is all I wish to say.
§ BARONESS GAITSKELL
My Lords, I apologise to the noble Lord if I accused him of shouting when he did not shout. All I really meant by my interjection was that the noble Lord and his supporters and followers would be doing a far greater good if they were shouting and marching for more and safe contraceptive methods.
My Lords, may I thank the noble Baroness, and say that I shall be delighted to march, though not to shout, for them as soon as I know that they are absolutely safe.
§ 5.38 p.m.
§ LORD AMULREE
My Lords, I should like to thank the large number of noble Lords who have spoken in this debate. I have made a few notes of one or two of the points made, but I probably cannot read them, and after this long debate I shall not say very much about them. I would express my appreciation of the kind welcome the Bill had from the noble Lord, Lord Aberdare, speaking on behalf of the Government, and from the noble Baroness, Lady Serota, speaking on behalf of the Opposition. That was very encouraging. I should like at the same time to thank all noble Lords who have spoken in favour of the Bill. There are no particular points which I wish to raise with them.
To the noble Lord, Lock Brock, I say that I am sorry about the wording regarding treatment in Clause 1 of the Bill. Perhaps it will be possible to put that right as we go along. I would assure him that this work is not being done for the good of the State; it is being done for the good of the family. I think, too, that there will be no pressure brought by the Bill on doctors to do vasectomies if they do not wish to. I was very interested in what the noble Lord, Lord Craigmyle, said, but I would tell him that a great deal of work on vasectomy has been done 626 in the past. I have here a list of references going back to 1920, and I think I could, if I looked, find some that go back even before that. A great deal of work is being done on it now, but a good deal of work has been done in the past and, so far as we know, there have been no recognisable ill effects.
The right reverend Prelate asked whether the instructions, or whatever they are called, from the Department would be mandatory or purely advisory. I am afraid that I cannot give him a very satisfactory answer. At the present time, because they have not yet been worked out, they are called "guiding lines". But I am sure that, so far as possible, we shall see that people requiring vasectomy under this Bill will be required to have consultation on per haps more than one occasion with the family planning people. I am certain that the Bill would not apply to the young man who wanted to have the operation for other reasons. Of course one could not stop him from going to a venal doctor who might do it for him; but that is something which we must put up with.
I am thankful to the noble Lord, Lord Leatherland, for his intervention and I wish him good luck on his Golden Wedding which falls in the near future. The noble Lord, Lord Platt, said that the medical profession exists to carry burdens, and I think he is right. We quite often need to do, or have to do, something which we should rather not do. One noble Lord remarked how sad it was that after a vasectomy people could have no more children. The same argument applies to a woman who has been sterilised, and there may be all sorts of family dramas afterwards because she cannot have any more children. I think that what I have said covers all the points which have been raised.
§ On Question, Bill read 2a, and committed to a Committee of the Whole House.