Hysterectomy and other “hard” software (sensitive) questions

Recent media reports of a startling number of hysterectomies being performed in various Indian states have raised ethical concern in the public health community (1, 2). In our view, this is a perplexing health policy issue as it could result in serious side effects being apprehended in large numbers of young women, which would normally appear years later. We analyse the construction of the “need” for hysterectomy within the framework of relational ethics, which focuses on roles in relation to others, and the critical feminist intersectionality theory. The latter views the individual as an intersection of privileges and oppressions that jointly influence life choices as they relate to the ethical principles of autonomy, maleficence, beneficence, and justice.

The biomedically defined indications for hysterectomy include cancers of the cervix, ovary and uterus, endometriosis, fibroids, prolapse, chronic pelvic pain and bleeding. One in three women in the US underwent hysterectomy in their lifetime. Prevalence by age 50 in the UK is around 20%, and higher in Australia (3). The known adverse effects associated with it include depression and hormonal imbalances. In highincome countries, the woman is usually provided hormone replacement therapy (HRT) after the procedure.

The issue under scrutiny is the apparent rise in the number of hysterectomies being performed on much younger patients in India. Comparatively less attention is being paid to the longer term clinical, psychological and social consequences for the women concerned and for the wider Indian society. Is income maximisation possibly playing a major role alongside clinical necessity?

There are apprehensions about whether hysterectomy is warranted or unwarranted, and voluntary or forced (autonomy concerns). Who decides whether a woman should undergo this procedure? Is it the individual, the joint family, or an intermediary or middle-man who can shape the choice to opt for a hysterectomy? Which women, under what exigencies, are undergoing it or refusing to do so? Are primary healthcare doctors refusing advanced laparoscopic technologies while specialists interested in gaining clinical experience (and in making money in the private sector) are all too willing (beneficence/maleficence concerns)? What about following standardised treatment guidelines for choosing hysterectomy, especially among young women? There is also the question of advanced technology like laparoscopy – is the (ab)use of surgery/professionalisation the driving force (beneficence and justice concerns)?

Another aspect relates to gender constructions. Conventionally (at least, in our anecdotal experience), a daughter-in-law’s social status may become elevated within the family once menopause occurs. Maleness is considered a sign of power. Is this an underlying or even contributing reason to opt for a hysterectomy and escape from oppression in the family setting (justice concerns)? Certainly this issue warrants further critical examination, or at the very least, ethical rumination.

Varying notions of the need for hysterectomy are shaped by differing experiences of the utility of the uterus (making babies, defining womanhood), a related factor being ideas regarding its longevity (is a uterus needed after reproduction has taken place?). There is also a difference in terms of the biomedical constructions of risk to the uterus versus social notions of the risks of the uterus, which relate to the need for menstrual hygiene and more generally speaking, invisibilisation of women’s health. It could be said that on the one hand, the hegemonic public health habitus objectifies and atomises the female body in terms of just a uterus, while on the other, it casts women within a vulnerability paradigm (4) in which, as victims, they actually lose the agency of choice and self-determination with respect to their own bodies (again, justice concerns). In addition to these basic questions are those that emerge at intersection with other contingencies in which paternalism may be exercised. These include questions related to differently abled girls, orphaned girls, and females of a low socioeconomic status.

On the basis of the reflections above, it can be said that the issue of hysterectomy is, at bottom, a much larger and complex issue that is inflected by relationships between patients and providers, women and their families, women and the society, and even the somatic (woman-her own body) and the systemic (woman-the health system). These factors must be understood in a necessarily broader set of contexts as currently there is the lack of systematic research and understanding of the subject.