Reproductive ethics is a field I’m not all that familiar with, but it’s been a big deal lately, so I’ve been thinking about it a bit. The American Society for Reproductive Medicine has a few broadsheets on ethics, which are actually rather helpful. Reproductive medicine is a great field for looking at ethical problems. Let’s examine two of them to learn something about the ethics of the field (and of course, about ourselves as well):
Parental factors, that is, facts about the parents, may be important in reproductive medicine. When doctors become part of the reproductive process, someone other than the parents has a chance to say “no”. This leads to some interesting questions. Are there times when a doctor should say no to potential parents? I’ve written about this once before in the context of a lesbian who wanted to have a baby and was denied the services of a fertility doc. The professional guidelines are pretty clear, but let’s get a little more detail.
What parental factors should lead a doctor to deny reproductive services to a patient? Should we only help married heterosexual couples? Should the age of the parents matter? What about income?
The reasoning given for the statement on unmarried and gay patients is instructive (emphasis mine).
…An overarching ethical question is whether it is acceptable to help unmarried single persons or couples to reproduce, regardless of their sexual orientation. If it is ethical to provide such services, a second question is whether programs have a duty to treat all persons, regardless of their gender, couple status, or sexual orientation. Society has long since moved from restricting reproduction to heterosexual married couples. Although restricting reproduction to heterosexual married couples has many advantages, long experience has shown that not all deviations from this model necessarily harm offspring or society. As a result, we find that neither concerns about the welfare of children nor the need to promote marriage justify denying reproductive services to unmarried persons, including those who are gay or lesbian. Although professional autonomy in deciding whom to treat is also an important value, we believe that there is an ethical obligation to treat all persons equally, regardless of their marital status or sexual orientation.
Remember, ethics are not stored in some sky-vault—they are real-world tools to help describe and guide our social behavior. Ethics to a large extent depend on local conditions. They explicitly invoke societal good and societal values. They compare the values of the duty to treat all persons with the value of professional autonomy. Given that there is no clear harm to the children or to society in helping unmarried parents and homosexuals have children, the desire of the patient to have the service wins. Given the tug between the physician’s autonomy and that of the patient, the patient’s wins. This might not be true in all societies, but these values are a strong part of the medical profession, at least here in North America.
So what about other patient factors? What about “child-rearing ability”? What other factors should make us want to deny assisted reproductive technologies to a patient? Once again the ethics statement of ASRM is instructive, as much for process as for content (once again, emphasis mine).
1. Fertility programs may withhold services
from prospective patients on the basis of
well-substantiated judgments that those patients
will be unable to provide or have
others provide adequate child-rearing for
2. Fertility programs may–except in clear
cases of significant harm to offspring–
provide services to all persons who medically
3. Fertility programs should develop written
policies and procedures for making determinations
to withhold services on the basis
of concerns about the child-rearing capacities
of prospective patients.
4. A program’s assessment of a patient’s
child-rearing ability should be made jointly
among members of the program. A home
study is not required.
5. Persons with disabilities should not be denied
fertility services except in rare cases
when a well-substantiated basis exists for
thinking that they cannot provide or have
others provide adequate child-rearing for
This is sufficiently broad to allow all sorts of judgments about whether the patient will be a fit parent, but the important thing here is the process. Decisions to provide and deny care should be transparent, and available to anyone interested in the service. This does nullify any responsibility for the provider to behave ethically, but expectations that are clearly stated respect the dignity of the patient, an important ethical principle.
So there are qualities of the parents that affect the decision to give or withhold assisted reproduction. What about the process itself? Are there ethical issues to be found? How about EIGHT OF THEM!
High-order multiple pregnancies (greater than triplets) are considered a negative outcome. They are very risky for both the mother and the children. Fertility doctors who transfer multiple embryos are either making a mistake, or ignoring the ethical guidelines of their profession. This is an area where paternalism trumps autonomy. There is too much risk to mother and child(ren) when so many embryos are transferred, and no doctor should participate in this procedure. People just weren’t designed to have litters.