Many consider the plight of Native Americans an archetypal genocide. Centuries ago, the British suggested the response to their presence should be “extermination.”[1] Their soldiers then proceeded to knowingly decimate them with smallpox—a virus to which Native Americans had no immunity. Additional efforts over centuries to eradicate their population would follow. There would be a “Trail of Tears,” lethal attacks on Nez Perce men, women, and children to acquire their ancestral homeland, and a massacre at Wounded Knee—to name merely a few. The protracted policy directed against the United States of America’s indigenous peoples represented misguided governments, widespread greed, and enforcement by an at times ruthless, undisciplined military. A recent, albeit weakly publicized, continuation of this policy has been played out in a bioethical arena. Indeed, after the Nuremberg Trials and an explicit international consensus, this would be considered anathema. On view is the evil of forced abortions and sterilizations. This two-pronged approach to knowingly limit births in selected populations was emblematic of eugenic policy in the early to mid-twentieth century. Unfortunately, eugenic birth control had been resuscitated as late as the 1970s through voluntary physician complicity with an immoral national eugenic policy.

When she was 20 years old, a Native American woman underwent a total hysterectomy by an Indian Health Service (IHS) physician for unconvincing indications.[2] Her experience came to light when she visited Dr. Connie Pinkerton-Uri, a physician of Native American heritage in the 1970s. Two other young women in Montana needed appendectomies and also received “incidental” tubal ligations. Were these merely aberrations or the first examples of a disturbing pattern? Bureau of Census Reports explicitly documented a steep decline in childbirth for diverse Native American tribes comparing birth numbers from 1960 through 1980.[3] The three examples were, unfortunately, merely the tip of the iceberg.

On November 6, 1976, the Government Accounting Office (GAO) released the results of its investigation into similar events at four of twelve IHS areas (Albuquerque, Aberdeen, Oklahoma City, and Phoenix). Records verified that the IHS performed 3,406 sterilizations between 1973 and 1976.[4] “Tip of the iceberg” is indeed an appropriate metaphor. Per capita, this figure would be equivalent to sterilizing 452,000 non-Native American women.[5] Albuquerque contracted out their sterilizations to local, non-IHS physicians; therefore their region inaccurately added zero procedures to the government count. Independent research estimated that as many as 25–50% of Native American women were sterilized between 1970 and 1976.[6] Independent verifications were critical. The GAO did not interview a single women subjected to sterilization. The GAO also admitted that “contract” physicians were not required to comply with any federal regulations (including informed consent) in the context of these surgical procedures. Study of consent forms utilized revealed that three different forms were in use. It also appeared the “consent,” in many instances, was obtained through coercion.

What may be the most disturbing aspect of the investigations followed: it was physicians and healthcare professionals in the IHS who coerced these women. It was they who abandoned their professional responsibility to protect the vulnerable through appropriate, non-eugenic indications for surgery and informed consent prior to the procedures. On a Navaho reservation alone, from 1972–1978, there was a 130% increase in abortions (a ratio of abortions per 1000 deliveries increasing from 34 to 77).[7] The same study demonstrated that between 1972 and 1978, sterilization procedures went from 15.1% to 30.7% of total female surgeries on that one reservation. Healthcare professionals’ coercive tactics included the threat of withdrawing future healthcare provisions or custody of Native American children already born—if consent for sterilization was withheld.[8] The scandal of this replay of earlier twentieth century eugenic programs and genocidal tactics led to a congressional hearing (Senator James Abourzek, Democrat, South Dakota), but little else in terms of publicity, justice, or public outcry. It has also not been scrutinized from a careful bioethical perspective.

Although the travesty of forced sterilization and abortions targeting Native Americans occurred a generation ago, and has apparently ended, a revisit in 2009 is critical. First, the breech in ethics took place in America. The record for such immoral activities has already been questioned in light of California’s record with forced sterilization from 1909 through 1979, subsidized through federal funding.[9] Approximately 20,000 similar operations were performed in that State (mostly on African-Americans and Latinos), a significant number of these occurring after the Nuremberg Trials. Secondly, if the centuries-long treatment of Native Americans is a protracted genocide, not merely archetypal, the addition of physicians to the armamentarium of genocide, especially at this late juncture, is ominous. Physicians in the IHS during the time in question were young. Since their generation, additional medical graduates have moved even further from the Hippocratic tenet of “do no harm.” Furthermore, the ever-increasing shift from a covenantal model for medical practice to a contract model is relevant to the ethics at hand. Physicians who performed abortions and sterilizations on Native American women were contracted and reimbursed in full for their work. Similar models for specialty care which is contracted and reimbursed in full exist today under the umbrella of managed care. Payment for medical technique removed from context of ethical considerations may tempt many physicians in an era of decreasing reimbursement rates. Erosion of Hippocratism inhabits every aspect of the tragedies of care for these Native American women, and serves as more than a warning to us of the danger of divorcing ethical conviction from medical care.

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