Book Review

Coerced Contraception? Moral and policy challenges of long-acting birth control

N Engl J Med 1997; 336:1765June 12, 1997

Article

Coerced Contraception? Moral and policy challenges of long-acting birth control
(Hastings Center Studies in Ethics.) Edited by Ellen H. Moskowitz and Bruce Jennings. 225 pp. Washington, D.C., Georgetown University Press, 1996. $45. ISBN: 0-87840-624-7

The Hastings Center sponsored a project on the ethics of policies and practices regarding long-term contraception, which included conferences and presentations held between 1992 and 1994. As part of its series titled Hastings Center Studies in Ethics, the center has published a collection of papers originally delivered at these meetings, representing authors from diverse backgrounds and professional orientations.

Several overt forms of coercion may affect women's reproductive autonomy. The use of contraception as a condition of parole has received widespread publicity. Welfare systems may try to influence childbearing decisions by decreasing benefits to women who continue to have children or withholding them altogether.

Other forms of coercion may be more subtle or complex; rewards may be considered coercive. In her chapter, “The Concept of Coercion and Long-Term Contraceptives,” Bonnie Steinbock draws a distinction between a token award, which she considers acceptable, and a significant award, which may be considered coercive in that it is difficult to reject. Health care providers should find the description of the development of the philosophical concepts of coercion informative and illuminating, but it raises more questions than it answers. For instance, if a token financial award is a recognition of positive behavior, then the award is not really financial, but social. Certainly social approbation or approval can be a powerful determinant of behavior and be every bit as coercive in some settings as financial incentives or penalties.

The use of a substantial monetary award — for example, a $500 payment to a woman for the insertion of Norplant — has been condemned as inappropriate. In reality, we know very little about the behavior of women who are offered such an award. Do women actually alter their behavior in such situations? Or do women who want Norplant anyway cheerfully pocket the windfall, leaving women who don't want it unaffected? If behavior is unaffected, then what is seen as a coercive policy within a philosophical framework becomes an unevenly distributed bonus that is of benefit to some women and of no harm to others.

In another difficult situation, a woman may seek or allow pregnancy when she is unable to care for herself or a child because of her own immaturity or disability. For instance, an adolescent may be pressured (or coerced) physically, emotionally, or socially into seeking or risking pregnancy. How much “pressure” to use contraceptives can her parents exert before it is unacceptable? Hilde Lindemann Nelson and James Lindemann Nelson conclude that parents have the “moral standing” to insist on contraception for the well-being of their daughter and to avoid a situation in which they or someone else will have to care for a child borne by their irresponsible or unrealistic daughter. I fear that the “moral standing” argument can also be used to justify the incarceration of an adolescent or her partner, or forced marriage or childbearing, depending on the personal and social norms of the parents. The parents' insistence on long-term contraception for their daughter can be supported by health concerns; pregnancy carries more short-term and long-term risks than does Depo-Provera, and the parents are responsible for their daughter's health and safety.

The chapter by Ruth Macklin highlights the potentially coercive role of the health care provider in withholding care or choices in care. I found her example of inappropriate refusal to remove Norplant instructive. Macklin feels that “if this physician is unwilling to remove Norplant from any patient, he should not insert the Norplant in the first place.” This is a useful guideline, as consent for Norplant is obtained for a temporary device rather than a permanent procedure.

The chief drawback of this book is that the individual essays have little connection or coordination with one another. There are multiple accounts of the Darlene Johnson case, and one explanation of the characteristics of Norplant would have sufficed. However, all the chapters are well worth reading, and each can stand on its own. I suggest reading one or two at a time. This book would be an excellent basis for an ethics course or discussion series and should be of benefit to health care providers, social scientists, and even politicians.

Lynn Borgatta, M.D., M.P.H.
Planned Parenthood Federation of America, New York, NY 10012