Chronicles of communication and power: informed consent to sterilisation in the Namibian Supreme Court’s LM judgment of 2015

Abstract

The 2015 judgment of the Namibia Supreme Court in Government of the Republic of Namibia v LM and Others set an important precedent on informed consent in a case involving the coercive sterilisation of HIV-positive women. This article analyses the reasoning and factual narratives of the judgment by applying Neil Manson and Onora O’Neill’s approach to informed consent as a communicative process. This is done in an effort to understand the practical import of the judgment in the particular context of resource constrained public healthcare facilities through which many women in southern Africa access reproductive healthcare. While the judgment affirms certain established tenets in informed consent to surgical procedures, aspects of the reasoning in context demand more particularised applications of what it means for a patient to have capacity and to be informed, and to appropriately accommodate the disruptive role of power dynamics in the communicative process.

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Notes

  1. 1.

    See, for example, reporting on Botswana, the Democratic Republic of the Congo, Lesotho, and Malawi in [2], on South Africa in [35], on Swaziland in [6], and on Tanzania, Zambia, and Zimbabwe in [7].

  2. 2.

    We refer here to constraints in physical, financial, and human resources as elaborated in the judgment’s narratives to follow.

  3. 3.

    It is noted that her uterus was not removed, which the nurse had said was required, as the first respondent testified.

  4. 4.

    Neither the High Court nor the Court of Appeal explicitly commented on the validity of the informed consent processes for the caesarean sections as their validity was not before the courts. The courts did however hold all three cases to have involved emergency caesarean sections.

  5. 5.

    For a statement of legal principles, see [11, para. 78], and see the South African precedent in Castell v De Greef [12], Stoffberg v Elliot [13], and Esterhuizen v Administrator, Transvaal [14].

  6. 6.

    See the case of Pandie v Isaacs [15].

  7. 7.

    Pandie v Isaacs [15, para. 34].

  8. 8.

    See Lillicrap, Wassenaar and Partners v Pilkington Brother (SA) (Pty) Ltd [17, secs. 499A-500A, 501A-502G] and Van Wyk v Lewis [18]. See also Administrator, Natal v Edouard [19, secs. 595D-597H].

  9. 9.

    See Stadsraad van Pretoria v Pretoria Pools [20, sec. 1007H]. See also Pandie v Isaacs [15, para. 91].

  10. 10.

    See sections 2(2) read with sections 1 and 4.

  11. 11.

    See [23] as referred to in the Supreme Court judgment [1, para. 98].

  12. 12.

    Studies in Latin America have indicated that in many cases of women living with HIV who are coercively sterilised, healthcare workers deliberately misinformed patients in order to coerce their agreement to the procedure (see [24]).

  13. 13.

    The extent of the undue focus on the ‘consent’ stage of the informed consent process is seen in the response of certain public hospitals in Namibia to the Supreme Court judgment. Following the judgment, a number of women have reported being denied voluntary sterilisation procedures and being told that they need to obtain police affidavits indicating their consent to the procedure before it is performed [25].

  14. 14.

    The doctor testifying in relation to the sterilisation of the third respondent stated that sterilisation is normally performed 48 h or 6 weeks after the patient gives birth [1, para. 83].

  15. 15.

    See [26, p. 27] for a discussion on varying effects of pain during labour on a patient’s capacity to be informed for consent to epidural analgesia.

  16. 16.

    See the discussion of the 1972 case of Canterbury v Spence in [29].

  17. 17.

    See Castell v De Greef [12, para. 425].

  18. 18.

    See the discussion in [30, p. 313].

  19. 19.

    Supreme Court judgment here cites the Health Professions Councils of Namibia’s Ethical Guidelines for Health Professionals [31].

  20. 20.

    See the ‘Bolam’ principles as articulated in Bolam v Friern Hospital Committee [32]. See also Sidaway v Governors of the Bethlehem Royal Hospital [33].

  21. 21.

    These principles in Castell v De Greef [12] were developed in reference to jurisprudence in Canada and Australia, including Rodgers v Whitaker [34] and Reibl v Hughes [35], in which the Bolam principles approach was rejected.

  22. 22.

    Supreme Court judgment [1, para. 107]: ‘I am not persuaded that the appellant has discharged its onus of demonstrating on the balance of probabilities that informed consent was given’.

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Correspondence to Annabel Raw.

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One of the authors of this study was involved in the litigation at the Namibian Supreme Court in support of the three respondents.

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Chingore-Munazvo, N., Furman, K., Raw, A. et al. Chronicles of communication and power: informed consent to sterilisation in the Namibian Supreme Court’s LM judgment of 2015. Theor Med Bioeth 38, 145–162 (2017). https://doi.org/10.1007/s11017-017-9405-0

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Keywords

  • Informed consent
  • Sterilisation
  • HIV/AIDS
  • Human rights
  • Namibia
  • Southern Africa