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On sterilising severely mentally handicapped people.

At the time of writing, the House of Lords in England had not ruled in the case ofJeanette-a seventeen-year-old with allegedly the skills of at most a five or six-year-old whose mother and gynaecologist wished to perform probably irreversible sterilisation by an operation to tie her fallopian tubes (1). Whatever the legal decision, the ethical issues underlying decisions of this kind deserve analysis. In the normal case the matter is settled by the decision of the woman and her gynaecologist-if she wishes to be sterilised, for example for the purposes of contraception, and a gynaecologist agrees to her request that is the end of the matter so far as the law in England is concerned (2). The underlying ethical argument may presumably be simply but perhaps not inaccurately summarised along the lines that such sterilisation is an operation of sufficient potential benefit and sufficiently small likely harm to be justified if a patient understandingly and autonomously chooses it, and that there are no generally overriding considerations of justice, either in terms of people's rights or in terms of distribution of resources, to prevent such operations. What changes the ethical argument in the case of a severely mentally handicapped person is of course the absence of sufficient autonomy in the potential patient to make possible her understanding and autonomous choice either to have or not to have the operation. We have developed, however, several apparently justifiable systems for dealing with cases of inadequate autonomy. In general the preferred approach is to try to approximate as closely as possible to what would be the autonomous decision of the person concerned (for instance by reference to earlier expressed autonomous preferences and decisions). That route is blocked however in the case of those people who have never developed sufficient autonomy, such as those who have been severely mentally handicapped from birth or early childhood. The second route is that commonly adopted in the case of children, where autonomous decisions are exercised by proxy on the child's behalf. The normally acceptable proxies are the parents (and there is argument as to whether they should exercise their proxy autonomy in the child's best interests or merely in the child's interests). The assumption that the parents are the appropriate proxies is however defeasible, certainly when there is reason to believe that they are unjustifiably acting against their child's interests and arguably even if they failing to act …