Dr. Joe Wilkins delivered Carol Mason's first daughter 3 years ago, and her second daughter is due in 6 weeks. Mrs. Mason's pregnancy has been uncomplicated so far. At her last regular check-up a month ago, Mrs. Mason, who is now 33, asked whether Dr. Wilkins would "tie her tubes" at the time of the delivery. Dr. Wilkins agreed to do so.
At this visit, Mrs. Mason brings up the topic again and requests that Dr. Wilkins not tell her husband, John, about the tubal ligation. "I know he would like to have more children, and really wants a son," she explained.
"You're my patient, and there is no reason for me to tell your husband," Dr. Wilkins replies, "but you should think about the consequences of not telling him. He'll expect you to become pregnant again and wonder why you're not."
"I know, but I don't want any more children. I'm establishing a career that's important to me. John and I have had this conversation a dozen times, and it goes nowhere. The bottom line is, it's my body and I don't want any more children. But I just wanted to warn you that as soon as John sees you in delivery, he's going to ask how it went and whether it looks as though everything's all right for me to have more babies."
Mrs. Mason's physician is correct to maintain patient-doctor confidentiality–it is indeed Mrs. Mason's body, and she has the right to make her own reproductive decisions. For instance, the courts have consistently struck down "husband notification" requirements in state abortion laws, and the same legal principle applies in this case. There is no legal obligation to inform the husband (or father, if the husband is not the biological parent).
Nevertheless, Mrs. Mason's request for a tubal ligation, without her husband's knowledge, is troubling and should send up red flags for the physician. Dr. Wilkins would be wise to further explore the reasons for the requested deception. Are there any outward signs that Mrs. Mason's husband is physically abusive? Is Mrs. Mason in danger of triggering a round of abuse if she reveals her planned action to her husband? Husbands who are abusive often try to isolate their partners. Mr. Mason's preference that his wife have more children rather than pursue her career may be indicative of this pattern. She is also asking Dr. Wilkins to act as a "barrier" between herself and her husband—another sign that there is fear in her relationship. Dr. Wilkins should be prepared to refer Mrs. Mason to domestic violence service if this is the case. If it is an abusive relationship that Mrs. Mason decides to end, she may have sacrificed her ability to have children with a different future partner—a decision she may later regret.
If this is not an abusive relationship, it is a troubled one. Mrs. Mason's actions are morally questionable. If indeed her husband is a caring father and partner, she may be seriously restricting her husband's future reproductive options by taking this action without his knowledge. Dr. Wilkins is right to encourage Mrs. Mason to be truthful and open. Her husband will no doubt learn of both the tubal ligation, as well as the deception, sooner or later. If she has post-operative complications and her husband is responsible for her care, he will learn of it sooner. Mrs. Mason may then well end up divorced and a single mother, or worse, in a contested divorce where her actions may be used against her in a custody battle. The physician has a responsibility to forewarn her not only of the medical but of the social consequences of her deception.
If confronted in the operating room, or elsewhere, by Mr. Mason about the possibility of future children, Dr. Wilkins should encourage Mr. Mason to treasure the two children his wife has already given him and, together with his wife, discuss their reproductive future.