Welcome to Ethics Consult -- an opportunity to discuss, debate (respectfully), and learn together. We select an ethical dilemma from a true, but anonymized, patient care case, and then we provide an expert's commentary.
Last week, you voted on whether a doctor should agree to voluntary surgical castration.
Should Dr. Hunnicutt agree to remove Warren's testicles surgically?
Yes: 70%
No: 30%
And now, bioethicist Jacob M. Appel, MD, JD, weighs in:
Castration -- both chemical and surgical -- has recently gained renewed attention from physicians and policy makers as a way to prevent recidivism, which is a problem among sex offenders. In the 1960s, sexologist John Money at Johns Hopkins University pioneered the use of a contraceptive hormone, medroxyprogesterone, to reduce libidinous urges among pedophiles.
California imposed such treatment upon a small segment of repeat sex offenders in 1996. In 1997, then-governor George W. Bush signed legislation that made Texas the first state to allow prison inmates to choose surgical castration voluntarily.
Over the past two decades, a number of states have enacted laws either allowing or requiring some form of castration for certain offenders. Often, these statutes operate in conjunction with "civil commitment" laws, which enable states to keep convicted sex offenders locked up in hospitals after their sentences have expired on the grounds of ongoing dangerousness. Some offenders elect for castration as a means of reducing unhealthy desires or demonstrating their commitment to avoiding future offenses. Critics condemn these policies as inherently coercive. They also note the significant medical risks and side effects involved in chemical castration and the irreversibility of the surgical procedure.
A meaningful assessment of the ethics of castration -- whether forced or voluntary, surgical or chemical -- might take into account its efficacy. Unfortunately, the data remain mixed. One widely cited , conducted by Reinhard Wille and Klaus Beier, reported only a 3% recidivism rate among castrated sex offenders, compared with 46% among those not castrated. However, an analysis by Mary Barker and Rod Morgan in Great Britain questioned the effectiveness of such treatments, noting methodological problems in many studies. For instance, some researchers have included those convicted for consensual homosexual relationships among "sex offenders" -- clearly creating a skewed and inappropriate sample.
A comprehensive , conducted by Linda Weinberger and colleagues, concluded that castration "alone, without attendant psychological change, may be insufficient to mitigate sexual recidivism in a person who is in the community and subject to temptations."
Conflicting data might also reflect variability among the motives of so-called sex offenders. While some might commit their crimes as a result of pedophilic urges, others may be driven by anger or have acted under the influence of illicit drugs. These latter individuals appear less likely to be tempered by castration. In Warren's case, as his goal is to reduce sexual urges, castration may help, but it is also a significant and irreversible mutilation of his body.
Since Warren is on Medicaid, one must also decide whether the taxpayers should pick up the tab for his surgery. Warren might make his case on medical grounds -- namely, that his urges are causing him significant psychological distress, and that no cheaper safe alternative treatment appears to be available. Or he could frame his argument in the name of the public welfare.
Even if the odds of Warren acting on his fantasies are low -- as he has not yet acted upon them in five decades -- if he did, the consequences would be devastating. Preventing an episode of child abuse seems worth $18,000.
The amount is also likely far less than the economic cost of trying and imprisoning an offender or providing social services for a victim. Opponents of such coverage might counter than this intervention is no different than other high-cost experimental medical interventions that are generally not covered by public insurance programs.
Jacob M. Appel, MD, JD, is director of ethics education in psychiatry and a member of the institutional review board at the Icahn School of Medicine at Mount Sinai in New York City. He holds an MD from Columbia University, a JD from Harvard Law School, and a bioethics MA from Albany Medical College.
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