Prescribing Male Contraceptives: Ethical Considerations
There have been a series of interesting comments on Twitter about the ethical dilemma involved in prescribing male contraceptives, prompted by my recent essay for Aeon Magazine. Here is the relevant excerpt from the Aeon essay:
The discontinuation of the WHO/CONRAD trial was a major setback in bringing male contraceptives to the market. It also raised difficult ethical questions about how to evaluate side effects in male contraceptive trials. Since all medications are bound to exhibit some side effects, what side effects should be sufficient to halt a trial? Female contraceptives have been associated with breakthrough bleeding, mood changes, increased risk of blood-clot formation, as well as other side effects. Why should we set a different bar for male contraceptives?
The twist here is that female contraceptives prevent unintended pregnancies in the person actually taking the contraceptive. Since a pregnancy can cause some women significant health problems, the risk of contraceptive side effects can be offset by the benefit of avoiding an unintended pregnancy. However, men do not directly experience any of the health risks of pregnancy — their female partners do. Thus it becomes more difficult, ethically, to justify the side effects of hormonal contraceptives in men.
The usage of female hormonal contraceptives has been associated with a higher risk of blood clot formation, but pregnancies carry an even higher risk for blood clot formation and other medical complications. Doctors can make the reasonable argument that the benefits of a contraceptive outweighs the risks for their patient - and prescribe it.
The situation is a bit different when it comes to male contraceptives. I will try to illustrate this with a hypothetical scenario, in which there is a male contraceptive on the market.
Mr. Solo has an appointment with his family physician Dr. Crusher, who informs him that he is in perfect health. Mr. Solo then asks if he could receive a prescription for the newly approved male contraceptive. Dr. Crusher explains to him that this new male contraceptive has a 1% risk of causing side effects such as major depression.
Mr. Solo responds that he and his partner Ms. Amidala-Skywalker have decided not to get pregnant - at least not in the near future. Mr. Solo is very concerned about Ms. Amidala-Skywalker's family history because her mother had a very difficult pregnancy and even died during childbirth. Ms. Amidala-Skywalker is not as worried about her pregnancy as Mr. Solo is and she does not want either of them to be permanently sterilized, but she and Mr. Solo have agreed to at least postpone having children for a few years. Ms. Amidala-Skywalker has been on an oral hormonal contraceptive for the past years.
Just prior to seeing Dr. Crusher, Mr. Solo was browsing some reading material in the waiting room and came across the magazine "Women's Health" in which he read that women who regularly use hormonal contraceptives are at a higher risk for blood clot formations and maybe even strokes. All these years, his partner has been taking hormonal contraceptives and exposing herself to this higher risk. Since they both agreed not to have children at this point in time, Mr. Solo feels that it would only be fair if he now started using a male contraceptive and gave his partner a break. He does not mind the 1% risk of side effects, after all, she has been taking the "pill" for so many years and he believes that a true partnership is based on an equitable sharing of risks.
Dr. Crusher tries to dampen his enthusiasm. She says that she respects his desire to be fair towards his partner and she also wants to be supportive of their decision not to have a baby. She understands their concerns about the health risks that Ms. Amidala-Skywalker would face if she became pregnant.
However, Dr. Crusher explains to Mr. Solo that she has a doctor-patient relationship only with him - not with his partner. Dr. Crusher feels comfortable prescribing a medication for a patient when the patient derives a net health benefit from it. She agrees that Ms. Amidala-Skywalker's well-being is important, but the health of Mr. Solo's partner (or of any other family member) is not her primary concern. She does not see how she can justify subjecting him to a 1% risk of side effects and declines to prescribe it.
I am not suggesting that this is the best way or the only way to analyze the ethics of prescribing a male contraceptive pill which has some side effects. Not everyone has to agree with Dr. Crusher's choice to focus only on the risks and benefits for her patient and to ignore the greater good or the medical benefits for his partner. These are the kinds of ethical dilemmas that physicians have to grapple with when it comes to addressing the issue of side effects associated with male contraceptives. Concerns about such ethical dilemmas and potential legal repercussions can act as deterrents for physicians and pharmaceutical companies.
But this does not mean that we should abandon the quest for male contraceptives. Doctors perform cosmetic surgeries without any medical benefits, despite the fact that some of the procedures can result in major complications. Physicians prescribe Viagra for men without a clearly defined medical indication even though Viagra can cause significant side effects.
If patients, healthcare professionals and the general public can find ways to ethically justify the risks of cosmetic surgery, it should be possible to resolve the dilemmas surrounding the prescription of male contraceptives. Instead of just maintaining the status quo in which women shoulder most of the burden and responsibility of contraception, we have to educate ourselves about alternatives and address the scientific, medical, ethical, political and cultural obstacles that prevent the development of newer male contraceptives.