White Coat Underground

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
offspring.
2. Fertility programs may–except in clear
cases of significant harm to offspring–
provide services to all persons who medically
qualify.
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
offspring.

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.

Comments

#1 Epinephrine
February 5, 2009

People just weren’t designed to have litters.

Sounds like a corollary of “People weren’t designed”
#2 Lilian Nattel
February 5, 2009

This is a tough one. I was just talking with a friend today about this. There is a story in the news here about a 60 year old woman who went to India to get treatment to conceive. Not only was she getting ivf, but she had to be treated hormonally in order to rejuvenate her uterus to hold the babies. Viscerally this does not sit well with me. But as my friend pointed out, then where would you draw the line. I think the same standards of treatment have to be given to everyone. If as a society we are going to have doctors offering ivf or offering to give hormonal treatments than it has to be offered to everyone equally. Every situation doesn’t sit well with me but it isn’t my life. I also considered the parallel with adoption. As a prospective adoptive parent you have to pass the scrutiny of a home study and whatever other legal parameters are prescribed not only by your own country but also by another country if you adopt internationally. But those are living children who are under the guardianship of someone who is looking out for their interest. Unless we as a society are going to give out licenses to test and then license all prospective parents, I think we have to put up with those situations that we don’t approve of personally. There are plenty of parents who don’t have reproductive assistance who should never be parents. And who those people are is not universally agreed upon either.
#3 Joe
February 5, 2009

Pal, in this case, wasn’t it grossly incompetent to instill eight (8!!, or more) fertilized ova into the woman (regardless of her history)? They say that bad cases make bad law, one can only hope that this does not lead to bad notions in ethics.
#4 PalMD
February 5, 2009

It was clearly wrong, and clearly against the guidelines of the profession (sorry, i thought i made that clear).
#5 Elissa
February 5, 2009

This may be totally off topic but – is California a state where assisted reproductive technology is commonly covered by insurance? It’s not in my state – a friend & his wife had to come up with $10,000 to go through IVF. In effect, where it’s not covered by insurance, that pretty much serves to deny care to couples who can’t come up with that kind of cash. (On the other hand, I’m not sure what effect it would have if insurance companies were to cover it – I don’t really know the ins & outs of health care / health insurance finance.)
#6 Joe
February 5, 2009

Sorry, I think if I had read more carefully, I would have understood that.
#7 PalMD
February 5, 2009

no, if I had written more clearly, you would have understood it.
#8 Danimal
February 6, 2009

People just weren’t designed to have litters.
Ehem, I think you meant “People didn’t evolve to have litters.”
#9 Dianne
February 6, 2009

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?

Studies comparing children raised by gay and lesbian couples have found that they are essentially indistinguishable from children raised by straight couples. So clearly denying reproductive services (including adoption) to gay or lesbian couples would be an immoral act of prejudice and have no relation to protection of potential children. Single parents one might want to investigate a little, but most single parents do fine so a general rule that no person not in a stable relationship could use reproductive services is clearly not reasonable.

Income? One might consider the extremes: it might be best to not help a woman who made her living by asking for spare change on the street to have a baby–at least not as an isolated act. Helping her get off the street, get a job and/or education, resolve any mental or physical problems that might have driven her onto the street, etc then helping her have a baby seems reasonable. Other than that it’s not clear to me that any particular income is either necessary or sufficient to ensure good child care.

Age? Eh, I don’t know. Does anyone know of any studies of outcomes of children born to women who were perimenopausal or later? Hard to say what sort of rules to make without data. If the data really doesn’t exist (as opposed to simply that I don’t know it) it might be reasonable to restrict reproductive services to women over, say, 50 to a clinical trial with close follow up to try to get the data on whether it’s a good idea or not.

On the other hand, a quick investigation of whether the “infertile” woman seeking treatment already has 6 children or not seems a good idea. And I’ve seen studies suggesting that implanting a single embryo is as likely or nearly as likely to lead to a successful pregnancy as implanting multiple embyros so I don’t see any reason to implant more than one. Maybe after multiple rounds of failed IVF as a last maneuvor before giving up, not certainly not initially.
#10 catgirl
February 6, 2009

High-order multiple pregnancies (greater than triplets) are considered a negative outcome.

I think this is the most important point to make. Becoming pregnant with octuplets isn’t a miracle, it’s a huge risk. The miracle is that they all survived. The mistake wasn’t in treating this woman; the mistake was transferring too many embryos at once. If she had split them up over several years to have 4 sets of twins, it would have been much less risky, and the children probably would have turned out healthier.
#11 sarah cookson
February 6, 2009

unbelievable that any obstetrician could behave in this way . no woman in australia with six ivf kids already would get further embryos implanted let alone eight at once. this guy should be jailed. whyarent you people totally up in arms? we would be?!! it’s not a gay / single / i want kids thing ,it ‘s an obstetric disaster of major proportions, and for californians, a nasty precedent.
#12 Stella
February 9, 2009

please see the link >

http://beware-of-the-fertility-industry.blogspot.com
#13 SAC
February 12, 2009

It is not recommended by experts that fertility experts place more than two blastocysts in the prepared uterus of a woman less than 35. Data supports this practice. Specifically, the data states that pregnancy rates are a tad bit higher if 2 blastocysts are placed compared to 1 in women less than 35 BUT no greater if 4 blastocysts are placed compared to 2. i.e. there is no reason to place more than 2 blastocysts in a woman under 35 and the risk of multiple pregnancies, preterm labor, low birth rate, death of the child and mother are much higher….