Vasectomy Provider Decision-making Balancing Autonomy and Non-maleficence: Qualitative Interviews with Providers

"The findings can be used to design trainings and policies that address supply gaps in vasectomy access that will, in turn, address persistent demand gaps."

Despite the high efficacy, low risk, low cost, and gender equity benefits of vasectomy, just 2% of women reported that they and their partners relied on vasectomy (male sterilisation) as their contraceptive method globally in 2019. The contributing factors to low global vasectomy uptake are multifactorial and interrelated, but can be understood as policy, demand, and supply barriers. For example, persistent low demand for vasectomy is fueled by lack of awareness, myths and misconceptions, and gendered norms surrounding virility and male health-seeking behaviours. This study sought to describe the decision-making rationales of experienced vasectomy providers when evaluating patient candidacy for the procedure, which should be viewed as permanent.

Fifteen vasectomy providers belonging to the global Vasectomy Network google group (VNG) from seven countries participated in online interviews using a semi-structured in-depth interview guide. Providers were asked about their vasectomy training, their reasons for vasectomy provision, challenging cases they have faced, and approaches used to manage challenging cases. Vignettes were used to further elicit decision-making rationale. Thematic analysis was conducted.

The interviews revealed that pre-procedure counseling discussions were the primary stage and setting where providers determined and decided patient candidacy for a vasectomy. Counseling discussions offered an opportunity for providers to educate and for patients to provide their context. Pre-procedure counseling was considered valuable for protecting patients from vasectomy regret or coerced procedures; one provider believes the practice of pre-procedure counseling is part of overcoming the legacy of forced sterilisation. Some providers also highlighted the importance of pre-procedure counseling as malpractice lawsuit protection.

Pre-procedure counseling validated three foundational and essential components of patient candidacy: (i) patients' knowledge about the procedure, (ii) patients' clear understanding of consent prior to the procedure, and (iii) patients' clarity in choice to have a vasectomy. On the latter component: Many providers also asked patients directly, particularly young patients, about whether they had considered the potential of regretting the decision at a later point and if they had considered other contraceptive alternatives for the time being. Patients who exhibited complex decision making, or acknowledged the potential for regret but still wanted the vasectomy, were more likely to be considered certain and therefore candidates for vasectomy than those who did not acknowledge the potential for regret.

Once those foundational conditions were met, providers filtered patient characteristics through their training, laws and policies, sociocultural norms, experience, and peer influence to produce a cost-benefit breakdown. For instance, providers acknowledged that their decision-making was influenced by the social attitudes of the countries in which they practice. One provider practices in a conservative country that has been slow to implement a vasectomy programme. This participant noted that the general resistance to vasectomy and male involvement in family planning resulted in his implementing highly cautious procedures. A major concern for this provider is to avoid poor outcomes (such as regret) that could impact the promotion of vasectomy more widely. Conversely, providers in two less conservative countries noted social attitudes about the importance of patient autonomy influenced their approach to decision-making.

Based on the cost-benefit analysis, providers determined whether to weigh the ethical principles of autonomy (the right of patients to make decisions about their own health care) or non-maleficence (a provider's obligation to do no harm) more heavily when determining vasectomy patient candidacy. A few providers felt that vasectomy regret was a substantial harm, and as such, patients with a high chance of regret were not good candidates for vasectomy. Patients considered to have a high chance of regret included young patients, patients without children, and patients undergoing major life changes including pregnancy or divorce. For other providers, honoring a patient's autonomy included providing a vasectomy even if the provider felt the decision was wrong or had a high chance of regret. This group of providers was informed by experience, training, laws and regulations, and their sense of responsibility as providers.

Reflecting on the findings, the researchers note that providers described different assumptions about the role of doctors in medical decision-making processes, which shaped their ultimate prioritisation of autonomy or non-maleficence. Within this study, there were two distinct schools of thought about the role of doctors. The first group viewed doctors - and thus, themselves - as educators and a resource available to facilitate patient decision-making. The second group saw themselves as active and engaged arbiter of decision-making. These two operating paradigms are both appropriate and permissible within medical decision-making, but the educator approach - with its emphasis on full information and assisting with choice through providing perspective - may be more apt to drive patient satisfaction with their method of choice.

In conclusion: "There is a need to examine what kind of evidence is used and the way evidence is used to guide decision-making, as well as a need to practice reflexivity on how bias may shape decision-making. Future trainings of vasectomy providers should focus on evidence-based medicine, shared decision-making, and patient-centered care to ensure vasectomy provision that honors patient autonomy and rights."