In a multiparous adult woman with six prior cesarean sections who requests a seventh cesarean and is offered tubal ligation, should consent be obtained from (A) the patient (or her legal representative), (B) both patient and husband, (C) the patient with instruction to inform her husband, or (D) an ethics committee?

Consent for Tubal Ligation During Cesarean Section

The patient alone (or her legal representative if she lacks capacity) must provide consent for tubal ligation—consent from the husband is neither required nor ethically appropriate, and an ethics committee consultation is unnecessary for this straightforward autonomy issue. 1, 2

Core Ethical and Legal Principles

The fundamental principle governing medical consent is patient autonomy. The will of the adult patient who is capable to provide consent and make judgments must be respected in any case. 1 This applies to all medical interventions, including surgical procedures like tubal ligation. 1, 2

Key Requirements for Valid Consent

• The patient must be informed about the nature, significance, and scope of the procedure, including potential complications, risks, benefits, and alternative treatment options. 1, 2
• The patient must have capacity to understand these risks and benefits to make an autonomous decision. 1, 2
• Obtaining informed consent is a non-delegable duty that must be performed by the physician. 1
• Written consent with comprehensive documentation is required for surgical procedures that involve a degree of risk. 3

Why Answer A is Correct

Consent must be obtained from the patient herself (or her legal representative only if she lacks decision-making capacity). 1, 3 The competent adult woman has the sole legal and ethical authority to consent to sterilization. 1, 2

Patient Capacity Assessment

• Even if a patient is not legally competent under civil law, she might still be capable of expressing her wishes and participating in decision-making. 1
• The patient's ability to consent should be reviewed by the treating physician with regard to every therapeutic decision and documented in writing. 1
• In doubtful cases, psychiatric or neurological consultation may help determine whether the patient can make a sound judgment. 1

Why Other Options Are Incorrect

Option B (Consent from Both Husband and Wife) - WRONG

Requiring spousal consent violates the fundamental principle of patient autonomy and is ethically inappropriate. 1, 2 The husband has no legal standing to consent to or refuse a medical procedure on his competent wife's body. 1 This paternalistic approach prioritizes others' judgment over patient autonomy when the patient has capacity to decide. 2

Option C (Consent from Patient with Instruction to Inform Husband) - WRONG

While informing family members may be appropriate for support purposes, making it a requirement or formal instruction creates an inappropriate barrier to the patient's autonomous decision. 1, 2 The patient may choose to inform her husband, but this should not be mandated as part of the consent process. 1

Option D (Consult Ethics Committee) - WRONG

Ethics committee consultation is appropriate when there is genuine ethical uncertainty, conflict between parties, or questions about patient capacity—none of which apply to a competent patient making a straightforward reproductive choice. 1 This is a clear-cut case of patient autonomy where the patient has decision-making capacity and is making an informed choice about her own body. 1, 2

Special Circumstances: When a Representative Is Needed

Only if the patient is unable to give consent and make judgments should a representative (authorized according to local law) be involved in the decision-making process. 1 This representative must determine and act according to the patient's wishes and best interests, not their own preferences. 1, 4

Criteria for Incapacity

• The patient cannot understand the benefits, risks, and scope of the intervention. 1
• The patient cannot make an autonomous decision based on this information. 1
• This determination should be documented by the treating physician, potentially with psychiatric or neurological consultation. 1

Documentation Requirements

The consent process must include:

• Written documentation of the procedure details, including permanent sterilization. 3
• Disclosure of risks, benefits, and alternatives (including no sterilization). 1, 2
• Documentation that the patient understands the irreversible nature of tubal ligation. 1
• The patient's questions and concerns addressed. 3
• Signature of the patient and the clinician obtaining consent. 3