We thank Drs Henderson, Ringel, and Rezai for their letter about our call for ethically justified revision of the 30-day mandatory waiting period for tubal sterilization for patients covered by federal programs such as Medicaid. We agree that, as a matter of professional responsibility, there should be continued protection of vulnerable individuals from coercion concomitant with expanded access to tubal sterilization, when not contraindicated for medical reasons and when the patient consents. We believe that intent behind the law was good, but had unintended consequences that, we argued, should now be considered to have become unjust to women covered by Medicaid.

Drs Henderson, Ringel, and Rezai rightly emphasize that selected populations may need protection to reinforce professional responsibility, of the kind created by the new California legislation cited in their letter. Nonetheless, for the vast majority of women affected by the mandatory waiting period, there remains an ethically impermissible risk of changing physician behavior and delivery of clinically and ethically appropriate care. This is why we focused on source of payment discrepancy as a driving factor in access to care.

Our main purpose was not to propose a single solution, but to highlight the ethical issues and subsequent need for reform and to encourage dialogue aimed at identifying safe, just, effective, accessible long-term and permanent contraception to patients who desire it. Drs Henderson, Ringel, and Rezai have offered a proposed solution that should be given careful consideration.