Ethical considerations in using orchidectomy for social control

BMJ 1993;307:790-3 Mr K is a 59 year old man with a long history of persistent sexual abuse against children. His abusive behaviour began when he was at school and continued into his marriage. He abused his own children, and, despite many periods of imprisonment, he continued to abuse children each time he was released. His last period ofimprisonment was for 10 years. During that last period in prison Mr K became determined to end his abusive behaviour and formed the idea that orchidectomy would solve his problem by curtailing his sex drive. He petitioned the prison doctor to this end and received his support. After his release Mr K was referred to a psychiatric hospital and admitted for assessment for several months. While he was in hospital Mr K was offered chemical castration using goserelin but refused this because he regarded it as a temporary and incomplete solution. He wants a permanent solution to stop his abusive behaviour so that he can start to live a normal life. He is convinced that the operation will work and liberate him from his condition, which he compares to that of being a "leper." He feels desperate for surgery and threatens suicide. To support his campaign for castration Mr K has been on a hunger strike and has also contemplated castrating himself. The issue of consent has also been carefully considered and the view has been formed that Mr K is capable of using his judgment to come to a sound opinion. The Mental Health Act Commission has concluded that Mr K's ability to give consent is fundamental and that in addition the opinion of a number of experts should be sought and a decision made on the basis ofthe consensus view. When Mr K discusses the impact of abuse on his victims he freely admits that "it ruins a child's life," but he claims not to be aware of the long term consequences and psychological damage that abuse of children may have when the child grows up into an adult. Mr K's obsession with castration sits oddly in a culture that is committed not to use surgery to change or alter behaviour-perhaps with the exception of oophorectomy and hysterectomy in women with severe premenstrual tension and for people having sex changes. A surgeon might be convicted for assault should he or she perform this operation unless a body of medical opinion supported the surgeon's decision to operate. Mr K has perhaps another 20 years in front of him. I wonder whether the indecisiveness of the medical establishment will create a living hell for dozens more children, while it refuses to accept Mr K's own, extreme, solution. Instead the clinicians offer the uncertainty of goserelin, a treatment he rejects and which is therefore unlikely to work. The other altemative is imprisonment, a just solution if he reoffends but which does not face up to the need for our society to develop effective strategies to prevent child abuse or to treat persistent offenders when they are released from prison. There is no dilemma for Mr K, who feels that castration is a perfect answer for himself and society. There is no known "cure" for the obsessive abusive behaviour he displays, and, despite Mr K's strongly held view about castration, society has rightly drawn fairly clear boundaries that distinguish between therapeutic surgery and mutilation. If a body of medical opinion supported Mr K might it become a dangerous precedent for acts of mutilation to be carried out at the behest of the courts or even the media? On the other hand, perhaps the solution is simply to comply with the wishes of a dangerous individual who passionately wishes to change himself and protect society.