A Note on the Sterilization’ of Mental Defectives
- Author:
Tredgold, M.D., F.R.C.P., F.R.S.E.
The recently published Report of the Joint Mental Deficiency Committee of the Board of Education and the Board of Control has shown that the num- ber of defectives in the country is almost double that ascertained by the Royal Commission twenty years previously, and is at least 8 per 1,000 of the total population of the country. While it would be a mistake to assume that mental deficiency has increased to this extent in a single generation, for there is little doubt that the ascertainment by the former enquiry was incomplete^ it is, nevertheless, impossible to avoid the conclusion that an increase has occurred during this time, and that the problem has now assumed such a magnitude as to demand the most serious consideration by the community. The most important aspect of the problem is unquestionably that of prevention, and in regard to this it is very natural that the subject of sterilization should have attracted a large measure of public attention.
This subject was considered very carefully by the Central Association for Mental Welfare several years ago and in 1926 I wrote an article which was afterwards published as a separate pamphlet. This pamphlet is now out of print and I have been asked to write another note on the subject.
There has been no material change in the arguments for and against the sterilization of defectives. Its advocates make three main claims; first, that it would greatly diminish, if not entirely eliminate, mental defect; secondly, that even if it did not do this it would at all events greatly lessen the cost of these persons to the community; and thirdly, that, by allowing many defectives who are now in institutions to be at large, it would greatly add to their happiness. The first of these arguments is clearly based upon a complete misunder- standing as to the causation of mental defect. It is now generally recognised that the majority of cases are a result of ” inheritance.” It has consequently, not unnaturally, been assumed by those who have no great experience of defectives and who are unacquainted with the subject of heredity, that the mentally defective child must necessarily be the offspring of mentally defective parents. It is of the utmost importance to realise that this is not so, and that the defect of a child may be due to inheritance without its parents being similarly defective. The explanation of this paradox lies in the nature of the inheritance of these cases. Although some writers, chiefly in America, have attempted to prove that Mental Deficiency is due to the absence in the ancestral germ cells of certain definite constituents, and that transmission is in accordance with the laws formulated by Mendel, these attempts have been entirely un- successful. On the contrary, there is every reason to conclude that mental defect is not due to the absence from the germ of a definite factor, or even of a series of factors; but that it is the expression of an impairment of develop- mental potentiality. In other words, it is due to a qualitative rather than to a quantitative change; this change being of the nature of a germinal vitiation.
There is reason to think, however, that the amount of this vitiation varies not only in the germ cells of different individuals of the same stock but also in the germ cells of the same individual. Moreover, it is highly probable that even with vitiated germ cells the condition of the offspring resulting therefrom will be to some extent influenced by the nature of the ante-natal environment. The result is that, although the majority of mental defectives come of families whose germ cells have undergone vitiation, this change shows itself in many other ways than mental defect. In some individuals it may be manifest as Dementia Precox or other forms of Dementia. In others, as certain forms of insanity or mental instability. In yet others, it may be so slight and the envir- onment of the individual so favourable that it is not manifested at all, and he passes through life apparently normal. Nevertheless, it is probable that all these classes of persons are ” carriers ” of mental defect, and that a chance combination of adverse circumstances may at any time so embarrass the develop- ment of the impaired germ cells as to result in a mentally deficient offspring. It is thus seen that mental defect may be due to inheritance, as it un- doubtedly is in the majority of cases, without the parent or parents of the affected child being defective. As a matter of fact, my own observations show that, in relation to the total number of defectives, the proportion of those who are the offspring of a certifiably defective parent or parents is extremely small.
And I have no doubt that this is the general experience of all those who have investigated any considerable number of these cases. This, however, is a very important fact in relation to the preventive effect of the sterilization of defec- tives. For it follows that if every defective in existence a generation ago had been sterilized, the number of defectives to-day would not have been appreci- ably diminished. It also follows that if every defective now existing were to be sterilized, the result a generation hence would be insignificant. In short, in order to produce any marked decrease in the total number of mental defec- tives a generation hence, it would be necessary to sterilize, or otherwise prevent the propagation of, not merely those who are themselves defectives, but all those who are ” carriers,” that is to say, every person suffering from germ vitiation. Obviously, this is so utterly impracticable as to be impossible. It may be added that even could this result be achieved, it is yet practically certain that the factors which initiate that impairment of the germ cells, whose culminating manifestation is mental defect, are still in operation, and that consequently if every individual carrier were eliminated to-day, a fresh crop would soon come into being. We are compelled to conclude, therefore, that from the point of view of prevention, sterilization would not do what is claimed for it and that its results would be relatively slight. As a matter of fact, it has been applied for some years past in several of the United States, where some thousands of defectives have been sterilized; but there is no evidence that it has resulted in any diminution in the incidence of mental deficiency. The second claim of the advocates of wholesale sterilization is that, by permitting the discharge of defectives from institutions it would greatly de- crease their cost to the community. This is a statistical question, but unfortun- ately, we are without the statistics necessary to make a comparison. For while we know the cost of defectives in institutions, we have no sufficiently extensive figures showing their cost outside. It is to be remembered, however, that steril- ization will merely prevent propagation. It will not make defectives more stable or more efficient; it will not in any way lessen their social incapacity. Even the mildest grade are defined by statute as ” persons in need of care, supervision and control for their own protection or for the protection of others,” and this need would still exist even were they to be sterilized and discharged from in- stitutions. What would happen in this case would be that large numbers of defective men and women, youths and girls, who are now living by no means unhappy lives in well managed institutions, where they have companionship ?f their kind, and are engaged in useful and to some extent remunerative work, would again be thrown upon the world to shift for themselves. They would have to compete for a living against their more fortunate fellows, in a market already flooded with a superfluity of labour. They would again be the butts and tools of the ignorant, designing and unscrupulous. They would have no real companions, and they would inevitably drift into destitution, vice and crime. In other words, the liberation of defectives to an extent which would make an appreciable difference to the nation in the cost of their maintenance in institutions, would simply result in a return to the evil days which existed before the passing of the Mental Deficiency Act, and those who are familiar with those days know only too well how evil they were, and how wretched were the conditions under which thousands of mental defectives existed in this country before 1913. Large numbers of the feeble-minded then lived a harried existence between the workhouse, the refuge, the prison and the streets. Their cost to the community was spread in so many different ways and borne by so many different authorities that it is impossible to say what it amounted to, but there is not the slightest doubt that it was very considerable. And it was a cost accompanied by decided menace to the general well-being of the community, quite apart from any question of propagation, and for which the community received no return. The presence of mental defectives in a nation must always be an uneconomic proposition, but I am of opinion that, on the whole, institu- tional care is certainly more economical than were the conditions which formerly prevailed and which would again prevail were any considerable number of these persons to be discharged from such care.
There is, moreover, another important point which has to be considered in regard to this. It is well known that under the conditions which formerly prevailed a considerable amount of promiscuous sexual intercourse took place between defective young women and normal males, and to a less extent, between high-grade defective males and normal girls. It cannot be doubted that this would have been even much more prevalent had there been no fear of pregnancy and no risk of being mulcted of a weekly charge for the mainten- ance of offspring. Does any experienced social worker question for a moment that if this fear were removed, owing to these persons having been sterilized, such promiscuous sexual intercourse would be greatly increased? But it is intercourse of this kind which is the chief means of spreading venereal disease, and I do not think there can be the slightest doubt that the presence in the community of defectives who were known to be incapable of producing child- ren would be followed by a considerable increase in these diseases. Not only is the feeble-minded girl more amenable to sexual solicitation, but it is well known that her very defect makes her unaware of the danger of venereal disease to her health, oblivious of the need for treatment and undeterred by the state she is in from responding to further solicitation. The advocates of steril- ization may, and do, pooh-pooh this aspect of the question and affect to regard it as a thing which is not at all likely to happen, but I venture to believe that what I have stated will be endorsed by everyone having practical experience of defectives.
The third claim is that sterilization, by permitting the discharge of defec- tives from institutions, would conduce to their greater happiness. It is true that a small proportion of defectives do resent being detained in institutions. They object to the routine and the discipline. They dislike having to do any work. They would much rather be released from all oversight and control and be where they could do exactly what they pleased, how they pleased and when they pleased. Almost invariably, however, these are the very persons who have proved their utter incapacity for social adaptation, who are so fickle and unstable that no one will employ them, and for whom the supervision, against which they fret, is absolutely necessary in their own interests. It is exceedingly doubtful whether such persons would be any happier outside than inside an institution. But cases of this kind are in the minority. It mav safely be said that the majority of defectives are by no means unhappy in institutions. On the contrary, institutional life affords far greater opportunities for compan- ionship, recreation and amusement than they would obtain outside, besides shielding them from that constant reminder of inferiority which results from their incapacity to succeed in competition against their normal fellows.
So far I have been considering the question of sterilization as a general policy and a wholesale measure to be applied to all defectives. I think it is clear that it would fail to accomplish any of the things which have been claimed for it. It would have very little effect in preventing mental deficiency; it would not reduce the cost of mental defectives to the nation; and it would not really add to their happiness. In other words, on preventive, economic and humanitarian grounds, segregation, as a general policy, is far preferable to sterilization and is without its disadvantages. Segregation not only does all that sterilization would do in preventing propagation, but it does other things as well. It removes the many dangers to the well-being of society which would arise from the presence in its midst of a large number of unstable, un- trained and inefficient defectives. It is more conducive to their happiness. It ls> in the long run, almost certainly less costly; and, if carried out in suitably staffed and up-to-date institutions, it is attended with some degree of remun- erative return.
It is now necessary to consider another aspect of the question. It is recog- nised that there are many defectives who are stable and well conducted and for whom, after training in institutions, suitable employment could probably be found outside. In such cases the chief objection to their discharge from institu- tional care is the danger of procreation. The question therefore arises whether sterilization might not be made a condition of such discharge, and whether it might not be possible by its application in suitable cases, to reduce to some ex- tent, the number of persons in institutions. It is obvious that this is a totally different proposition to that of the wholesale and indiscriminate sterilization we nave hitherto been considering. It is also one which has received a considerable measure of support from persons having practical knowledge of defectives. It is therefore worthy of careful and serious consideration.
My personal opinion is that there are certain cases of this kind in which sterilization might well be an appropriate and desirable procedure. Its sanction w?uld, however, necessitate an alteration in the Law and the practical diffi- culty, to my mind, consists in drafting such legal definitions and regulations as would ensure its restriction to suitable cases. It must be remembered that emands for the discharge of patients who are quite unsuitable for discharge are very frequent and insistent. They come from parents, friends, lay com- mittees and authorities responsible for payment. If sterilization were legalized these demands would certainly be increased and there would be a very real danger of the operation being extended to those defectives who were quite un- suited to be outside institutions. In the minds of those who had not carefully considered the matter the discharge of these persons would appear so safe and it would unquestionably be used as a lever in favour of such discharge.
Now it cannot be too strongly emphasised that, whether sterilized or un- sterilized, institutional treatment has been shown by years of experience to be the most satisfactory means of dealing with the bulk of defectives. It cannot be too strongly insisted upon that, even if every defective now in existence were to be sterilized, the number of those unfitted to be at large (on totally other grounds than the danger of propagation), is so great that more institu- tional accommodation than now exists would have to be provided. There is a very real danger that the legalization of sterilization, even to a particular type of patients, would delay still further the provision by local authorities of in- stitutional accommodation, which is so urgently needed. Indeed, by giving rise to a false sense of security, it would not only do this; it would almost certainly also prevent the development of adequate methods of guardianship and supervision for those who might with safety remain in the communitv, did these methods exist. It would therefore react to the disadvantage alike of the community and the defectives. I do not say that these objections are insuper- able; but they are certainly serious and require careful consideration before sterilization, even if intended to be restricted to a particular class, were made legal.
I have not considered it within my province to deal with any objections to sterilization which might be made on religious or ethical grounds, although doubtless such would be advanced. Nor have I considered the question from the point of view of public opinion, although doubtless this is at present so unripe that much propaganda would be needed before there would be any chance of a Bill to legalize sterilization being passed by Parliament. In this short survey I have confined myself entirely to the biological, economic and social aspects of the question and I have done so without any personal bias either for or against the procedure. I have tried to show that, from these aspects alone, the matter is far from being so simple as is often assumed, especially by those who have little practical experience of mental deficiency. Indeed, it is not too much to say that it is one which simply bristles with difficulties and which certainly requires the most careful consideration before any alteration in the law is made. It is a matter in which panic legislation cannot be too strongly deprecated. At the same time, the problem of mental deficiencv has unquestionably now attained grave proportions. It is one which is intimately connected with many other important social problems, and the total number of defectives and their ratio to die general population are increasing. It is high time that a thorough investigation were made by some authoritative and impartial body into its causation, its relationship to other social problems and into any means, including sterilization, by which it might be prevented.
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