Is tubal ligation ethically appropriate for a patient with a public guardian?

A mid-twenties patient has fetal alcohol syndrome, obsessive-compulsive disorder, and intellectual disability. She has tried various forms of birth control and has found them all either unsatisfactory or ineffective. She already has two children. In health ethics and law, there is a common distinction between decision-making capacity, which refers to a patient’s ability to make informed decisions for herself, and competence, which is a legal designation. Capacity and competence are both presumed. Capacity is assessed by a physician; incompetency is determined by a judge.

In this patient’s case, she has a public guardian—i.e., a government employee who makes medical decisions on her behalf because she was previously found to lack capacity—and so is legally incompetent to make her own medical decisions. However, a more recent psychiatric assessment found that the patient has the capacity to consent to tubal ligation.

Previously, an obstetrician denied the patient’s request for tubal ligation because her guardian would not consent to it. However, the reason the guardian had not consented was that, in this jurisdiction (as in most jurisdictions in North America), guardians are explicitly forbidden from consenting to any sterilization procedure. In fact, the guardian fully supported the patient’s request and told the obstetrician this.

The obstetrician then consulted the clinical ethicist, who spoke to the OB, the patient, and the guardian, before recommending that it is ethically acceptable to proceed with the procedure. The ethicist also recommended that the OB get legal advice.