The ethics of IVF
The ethics of medicine is based around four key tenets or moral principles:
- Autonomy: the patient’s right to choose their treatment
- Beneficence: the imperative of the healthcare professional to act in the best interest of the patient
- Non-maleficence: the famous “first, do no harm’ maxim of healthcare professionals
- Justice: fairness and equality: i.e. who gets treated and at what cost to the community
These, sometimes overlapping principles can constitute a moral minefield if challenging decisions have to be made. However, in the field of IVF the situation is further complicated because we are considering the rights and ethical status of not one, or even two individuals..but a minimum of three: the male, the female and the – yet to be born – child. In the case of surrogacy and donation the rights and ethical status of donors and surrogates also need to be considered.
Strictly speaking, of course, the unborn child is not ‘the patient’. Yet even so the right to choose treatment (an issue related to the tenet of ‘autonomy’ mentioned above) in the IVF setting is complicated. For what is the IVF clinic to advise if both parents carry a genetic disorder, yet the parents are unwilling for whatever reasons, to have a pre-implantation diagnosis? Predisposition to genetic disorders is also not the only consideration. In some places in the world e.g. the UK it is a requirement of law that doctors, by bringing children into the world, should have a duty to ensure that the welfare of the children should be adequate.
Counselling/informed consent
The best advice here seems to be that properly counselled ‘informed consent’ seems to be the answer. Simply, this means that a patient should fully understand the risks as well as the benefits of any treatment, including the consequences of that treatment, which in the case of IVF includes the considerations of bringing a child into the world and being responsible for it for a minimum of around twenty years thereafter!
Counselling is therefore a prerequisite for couples seeking donor IVF according to HFEA guidelines, but best practice would suggest that it is often a first port of call for any couples seeking non-donor IVF. This allows patients fully explore, and to be sure, of their motivations prior to actually undergoing treatment.
The issue of informed consent is also very important in terms of the provision made for patients to understand technical issues of treatment and which options offer the best chance of success. The cheapest option may not be the best for them, yet it is possible that a more expensive option may offer only the same chance of success as a cheaper option. This can be an area of some ethical dilemma for individual practitioners who have the added pressure of time/cost issues placed on them as a result of commercial considerations. From an insurance point of view it is worth bearing in mind, that whatever decisions are made, either by the practitioner or the patients (after appropriate counselling and technical information) that appropriate documentation of the informed consent process is produced prior to any treatment commencing.
Acting in the best interest of the patient
The second tenet of medical ethics concerns ‘beneficence’ (defined above as the imperative for the healthcare professional to act in the best interest of the patient). And, as mentioned, this is complicated in the field of IVF by the need to also act in the best interest of the child, a being that does not exist at the time of initial consultation.
One of the key considerations for IVF healthcare professionals is what treatments might be appropriate, having looked first at factors that can negatively impact on fertility: e.g. smoking and obesity. A general rule of thumb is that patients should be offered the ‘simplest, cheapest, safest treatment that is likely to work’1. This is one of those areas where we also cross over into the area of ‘autonomy’ bearing in mind the patients right to information in order for the principle of informed consent to be applied.
Taking into account factors that might negatively impact on fertility also means looking beyond lifestyle factors such as smoking and obesity. It means seeking information from previous healthcare professionals who have previously had the patient in their care, particularly if those external professionals are aware that the patient is trying for a child and they support that decision. This ensures that considered treatment options are medically appropriate and that any previously prescribed medications are taken into account in terms of potential detrimental effects on conception.
First, do no harm
Almost by definition, IVF has limited success in an emotionally charged setting where many couples are open to the idea of ‘trying anything’ to conceive. This can sometimes prejudice decisions where the principle of ‘first doing no harm’ might come into play, even when the patient is very well informed. This applies particularly where new treatments come into play and are touted by the lay press despite a lack of rigorous evidence for their effectiveness. Such new treatments apart from being ineffective (with the attendant risk of failure and the emotional consequences of such) can also be actually harmful. The rule here is clear: seek evidence, and know the risks! And also make sure the patient knows them.
Another tenet in ‘first doing no harm’ is the duty of healthcare professionals to keep abreast of new developments and information. For instance, there are examples in the literature of where reliance on out-of-date testing protocols has resulted in inaccurate or imprecise results2.
Fairness and justice
IVF will, for the near future remain a contentious issue in terms of human concepts of fairness. Health resources are sometimes scarce, and often constrained by issues of access and finance. In certain countries various restrictions apply, which is why in the age of increased travel we are seeing the rise of cross border reproductive care. But clinics are not obliged to treat ALL patients that present at their door. There may be good reasons for denying treatment, but the doctrine of fairness and justice suggests that it is best practice to ensure that patients are absolutely clear as WHY treatment will not be offered.
So why might a clinic refuse IVF treatment?
Age: clinics will often set limits for female age
Single sex couples: there is no medical or socio-economic justification for denying treatment based on the sexual orientation of a couple. Previously, the idea of children from such unions not doing as well as those from heterosexual unions was flagged as an excuse, but research suggests that they do just as well if not better3.
Medically unfit patients: the problem here is that one clinic’s definition will differ from another’s. Obesity in both men and women is often an issue, but in the west, some 50% of women and 70% of men report as being overweight or obese. Clinics sometimes apply a ‘cut-off’ BMI, but usually this only applies to the woman despite evidence that the unfitness of the male may also impact on the potential child’s future health. Also within this category lie those for whom treatment is futile: this instance requires the application of the tenet of both beneficence and ‘first do no harm’ in order to remain in the domain of good ethical practice.
Although following the four tenets for medical ethics – autonomy, beneficence, non-maleficence, and justice provides a strong framework for good practice and resolving conflict (i.e. before it potentially arises), there are many other considerations to take into account, including the legal picture in each country where the clinic is located. And it should always be borne in mind that each individual patient picture is different and that there will never be a ‘one size fits all’ book of rules for ethical considerations in this area.
References
1. A Melton Clark. 2016. Ethics of IVF treatment: remember the patient! Organization And Management Of IVF Units. Springer Publishing. Chapter 14. P274
2. F Yarde et al. 2012. Anti-mullerian hormone as predictor of live birth in imminent ovarian failure. Human Reproduction. Oxford University Press
3. EC Ilioi, S Golombok. 2015. Pychological adjustment in adolescents conceived by assisted reproduction techniques: a systematic review. Hum Reprod Update. 2015. 21, 84-96
