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Last Updated: Monday, 8 October 2007, 11:36 GMT 12:36 UK
'Wait and see the best approach'
Doctors must do what is best for the patient
Medical ethicist Daniel Sokol considers the controversy stirred up by a mother's request for doctors to give her severely disabled daughter a hysterectomy to stop her from starting menstruation.

The ancient Greeks called the uterus "an animal within an animal".

They believed it could roam around a young woman's body, sometimes all the way up to the throat, causing hysteria and a range of other unpleasant conditions.

Over 2,000 years later, the uterus is once again in the spotlight, blamed in anticipation of causing a severely disabled girl grave distress.

A key question is whether the distress will be sufficiently profound to warrant a hysterectomy, with its associated risks and side-effects.

We simply do not know whether or not surgery will be in her best interests

That this question cannot be answered with any degree of confidence introduces a high level of uncertainty in the decision to operate.

We simply do not know whether or not surgery will be in her best interests.

Wait and see approach

My immediate response, when first reading the case, was to advocate a "watch and wait" approach to see how Katie copes with this additional challenge.

Perhaps, with time, she will not be as distressed as anticipated.

Perhaps less invasive alternatives will work.

Alternatively, menstruation could prove unbearable and a hysterectomy may be the best option.

Given the risks, trauma and the irreversible nature of the surgery, this precautionary approach has much going for it.

One source of controversy is that the surgery is not medically indicated. The uterus is healthy.

The short-term injury of a hysterectomy and the possible side-effects and complications will be incurred without clinical benefits.

This should rightly raise a red flag.

"If it ain't broke, don't fix it" is generally wise advice.

But what is the "it" in Katie's case?

Will it reduce suffering?

The uterus ain't broke, but her mother would argue that it is her overall well being that is threatened.

Clinical benefit is but one element of overall benefit.

Our evaluation of Katie's overall wellbeing when her periods start will be far more accurate than it is at present

As psychological and emotional factors play key roles in our happiness, we should not reduce well being to the mere functioning of bodily organs.

If we believe that one of medicine's aims is to reduce human suffering, then removing Katie's uterus may be medically indicated.

Others will disagree, giving medicine a different set of aims and perhaps calling the hysterectomy, unhelpfully in my view, a form of benignly intended mutilation.

It is notoriously difficult to imagine what others are feeling.

Studies show that chronically ill and disabled persons tend to rate their quality of life higher than healthy persons asked to imagine themselves in their situation.


Our imaginations are prone to overestimate the dreadfulness of future or hypothetical states.

Katie Thorpe and her mother Alison
Katie Thorpe's mother Alison wants her to avoid suffering

Are we falling foul of this tendency when anticipating that menstruation will be awful for Katie, and will continue to be so no matter how accustomed she becomes to it?

Our evaluation of Katie's overall wellbeing when her periods start will be far more accurate than it is at present.

Another reason for the "watch and wait" approach regarding surgical intervention.

I am not sure if this will have "disturbing" implications for other children, as some have claimed.

Those in favour of the procedure could say the opposite: that it will have positive implications for others.

Hold back on criticism

In any event, such rare cases will surely need to be considered on a case-by-case basis.

What matters more, at this time, is to focus on Katie's immediate situation.

In such thorny cases, decision-makers should make sure that all the relevant moral factors and plausible alternatives have been considered and that, whatever the decision, they can defend it with strong justifications.

When this is done, it is often more helpful to support, rather than criticise, the decision-makers, for their own psychological welfare is not infrequently bound with the decision and its outcome, and Katie's happiness too cannot be entirely separated from the happiness of her mother.

  • Dr Daniel Sokol is a Lecturer in Medical Ethics at St George's, University of London, and Director of the Applied Clinical Ethics course at Imperial College, London.



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