Voluntary Sterilization (Amendment) Bill Second Reading – Closing Speech By the Minister for Health Mr Gan Kim Yong

Mr Speaker, Sir, 

Let me thank all the Members who have given their views and voiced support for the Bill. Let me now address the comments and suggestions made by the various Members.

Call for Additional Protection and Safeguards for Minors

2      Members such as Dr Lam Pin Min, Asst. Prof Eugene Tan, Ms Denise Chua and Ms Mary Liew commented about the protection accorded to minors or young persons below 21 years of age. They have asked why we do not also require a Court order for minors undergoing sterilization when imposed an age requirement. They have expressed concern that these young people may not fully understand the consequences of such a procedure, and would not be able to make an informed decision due to their young age. I agree with their concerns.

3      Firstly, let me clarify that a young person below the age of 21 years who lacks mental capacity is given the same protection as that for an adult who lacks mental capacity. A Court order is needed before sterilization can be performed.

4      In the case of an unmarried young person (below the age of 21 years), who does not lack mental capacity, there are four levels of safeguards. First, the young person must give his or her own consent, unlike a case of someone lacking mental capacity. Second, his or her parent or guardian must consent to having the young person undergo such a procedure. Thirdly, section 3(3) of the Act requires the Doctor to give a full and reasonable explanation as to the meaning and consequences of such treatment, and obtain certification from such person that he clearly understands the meaning and consequences of the treatment. Fourthly, cases involving such young persons will be required to be referred to the hospital ethics committee for review. There are sufficient safeguards.

5      Let me elaborate. In dealing with unmarried young persons, the doctor needs to, first of all, satisfy himself that this young person is able to understand matters relating to procreation and sterilization. If this person is too young, and not mature enough to understand the doctor’s explanation on sterilization and its implications, the concern highlighted by Ms Faizah Jamal, the doctor cannot proceed any further. In such a case, there can be no informed consent, and without the young person’s informed consent, the doctor cannot perform the sterilization. This is regardless of the wishes of the parent or guardian.

6      For the young person who is mature enough to have sufficient understanding of the matter, the doctor will then need to assess if he or she really wants to undergo sterilization.

7      Members have requested that such young persons who want to undergo sterilization be properly counselled to ensure that they appreciate the gravity of the procedure and its consequences. The College of Obstetrics and Gynaecology of the Academy of Medicine Singapore, has set out good practice principles for medical professionals in the taking of informed consent. In the case of informed consent for sexual sterilization, the doctor has to counsel the person and ascertain the motivations for sterilization, explore all other non-surgical alternatives and reversible procedures available, and clearly outline all the risks, benefits and prognosis of the procedure. Only when the young person fully understands the implications and consequences of sterilization, can the doctor continue with the procedure.

8      Ms Faizah Jamal expressed concern that only 1 parent or guardian is required to give consent. Let me clarify, the consent of the parent or guardian in this case will act as a safeguard, and is required in addition to the young person’s own consent. The consent of the parent or guardian does not replace the consent of the young person. In fact, should the parent or guardian refuse to give consent, the doctor also cannot carry out the procedure.

9      To enhance our safeguards further, all cases involving minors who are not mentally incapacitated seeking sterilization will be referred to the Hospital Ethics Committee for review. The Hospital Ethics Committee will independently deliberate on whether the minor should undergo sexual sterilization. It will take into account all clinical, psychological, social and ethical aspects of the case. Directives will be issued to the licensees of healthcare establishments under the Private Hospitals and Medical Clinics Act to all healthcare institutions to mandate this. This is similar to the suggestions by several members including Prof Fatimah Lateef, Ms Denise Phua, and Asst. Prof Eugene Tan to have independent committees such as the Hospital Ethics Committees to assist in the decision-making process.

10      I am confident that there is broad consensus within our medical community in Singapore that doctors will be very cautious to perform sexual sterilization on an otherwise healthy young person in the absence of any strong medical grounds or justification.

Minimum Age & Parity Requirements as Social Planning Tools

11      Dr Lam had asked why the VSA did not impose any parity requirements based on the number of children a person has. I think it is best to leave the decision of family size to the couple.

Procedure and Fees Involved in Application for Court Order

12      Dr Lam Pin Min and Prof Fatimah Lateef had asked about the Court application process. They may become too complicated or be too costly, and pose an additional burden on families. I understand and appreciate these concerns.

13      MOH is working with the Courts to make the process as streamlined as possible. Mental capacity assessments are also available as a subsidized service in our restructured hospitals and polyclinics, and we will look into what can be done to help those who cannot afford the legal fees.

14      Several members like Dr Chia Shi Lu also suggested the inclusion of psychologists, counsellors and social welfare workers, in this decision-making process. Understandably, since such cases can be complicated and involve social factors and family-related issues, the Court may call for, and take into account, input from all relevant parties, if it deems appropriate to do so.

What IS Considered To Be “Best Interests”?

15      Ms Sylvia Lim cautioned that we ought to be mindful on how to determine what is in the “best interests” of a person who lacks mental capacity. Indeed, “best interests” is a seemingly simple idea, but in practice, it is often complicated by different factors and circumstances that are specific to a particular case. The MCA itself recognises this, and it provides a framework that offers guidance on what constitutes “best interests”.

16      Indeed, it is because the “best interests” of a person who lacks mental capacity is such a complex matter to determine, and more so when it involves the serious matter of sexual sterilization, we have decided that it should not be left solely in the hands of any one individual or caregiver, but should instead be decided by the Court, taking into account the doctor’s report and after considering all the relevant medical, social and ethical aspects of the case.

Numbers of persons sterilised and who had given consent

17      Prof Fatimah Lateef had asked who had been the decision-maker in the sterilization cases over the last 10 years.

18      In the vast majority (98%) of these cases, most people undergo the procedure because they have achieved their desired family size and decided not to have any more children. For these cases, the person himself or herself had decided and given their own consent to undergo sterilization.

19      During the period 2003-2011, there were only nine (9) cases where the patient underwent the procedure because of a history of mental illness or hereditary diseases. The records show that in 8 out of these 9 cases, the patients gave their own consent. There was only one case where consent was given by the person’s parent.

Checks & Audits to Ensure Proper Control

20      Dr Lam had asked how MOH would check whether the law is being followed by the institutions.

21      Under the regulations, every doctor who performs a sexual sterilization procedure on a minor is required to submit a report to MOH within 30 days of that treatment. MOH officers also routinely perform licensing checks for all healthcare institutions. During these inspections, officers will call up records and case files, including those of patients who have undergone VS in these institutions, to ensure that processes and requirements specified under the VSA have been complied with.

Public Consultation Period

22      Ms Denise Phua felt that the period for public consultation was perhaps too short. Our public consultation period of 4 weeks, was within the norm. Feedback channels have always remained open even after the consultation period was officially over. Nonetheless, we take Ms Phua’s feedback, and we will see how we can further improve on our consultation process in the future.

Conclusion

23      Mr Speaker, Sir, I have substantively addressed the main issues raised by the Members. The amendments seek to protect those who lack mental capacity, in mandating that the parent/guardian or spouse apply to the Court for an order allowing the procedure to be carried out. We also want to ensure that the VSA remains relevant and reflect current medical practice. These amendments will also bring Singapore in line with the UN Convention of the Rights of Persons with Disabilities. I appreciate comments by members about providing education and support to caregivers. Although they are not related to the amendments in the bill, I’m sure the relevant ministries and agencies will follow up on that. MOH will continue to monitor the situation on the ground, work with key stakeholders to ensure a smooth implementation.

24      Sir, I call the Members of the House to give their support to this Voluntary Sterilization (Amendment) Bill. Mr Speaker Sir, I beg to move.