Ethics In Assisted Reproductive Technology
By: Stephen R. Lincoln, MD, FACOG, GIVF
Recent public outrage and fascination with the "OctoMom," saga has refocused the spotlight on ethics in Assisted Reproductive Technologies (ART). Although the controversial story involving the California woman who recently gave birth to eight children is loaded with ethical missteps (should this patient have been treated at all, why did the doctor transfer so many embryos, who should take care of all these children, was this appropriate use of health care resources), the story has also allowed us to reexamine many other aspects of the field of ART from the viewpoints of patients, providers, society as a whole and, possibly, lawmakers.
When examining some of the ethical dilemmas we all face, it is important to be aware that advances in reproductive biology and techniques sometimes proceed faster than society can morally and legally grasp. Is it appropriate for society to make laws governing reproductive treatments today when a few years from now these laws may become obsolete? Take, for example, the number of embryos that should be transferred in In Vitro Fertilization (IVF). Ten years ago it was not uncommon for physicians to recommend transferring three to four embryos even in patients with a good prognosis for IVF. Today, our professional society, the American Society for Reproductive Medicine (ASRM), recommends transfer of no more than one or two in most cases. However, in older patients with poor prognosis, ASRM guidelines are flexible and allow physicians to transfer up to five embryos if the likely success rate for the patient is low. So if our lawmakers impose restrictions of no more than two embryos for transfer (as has been done in other countries), patients with poor prognosis will face an even greater struggle in trying to conceive.
If providers and patients do not act responsibly, however, society may feel obligated to step in with legal regulations. As providers we have to do a better job of "policing our own," when other providers are clearly acting outside the standard of care. Patients and providers together have to be responsible with health care resources when requesting specific treatments. This is true when deciding how many embryos to transfer in a case with a good prognosis, but this can be particularly difficult in a situation with a very poor prognosis.
More often than not, the dilemmas I face include whether to proceed with treatments when the chances of success appear to be extremely remote and other options, such as donor egg, adoption or stopping treatment. do not appear to be acceptable to patients. When providers and patients are at odds over the best course of action, it may be helpful to enlist the assistance of third party counselors. Physicians are learning that providing limited treatments, even in cases with a poor prognosis, may help a patient come to closure with their diagnosis and move forward. And all of us have anecdotes about the "one in a thousand" chance that resulted in the birth of a beautiful child. Still, it is most responsible if providers do not continue treatments over the long term for patients whose prognosis is extremely poor.
The field of Preimplantation Genetic Diagnosis (PGD) offers incredible potential for eliminating or reducing the chances of a child developing one of a host of inheritable disorders. We can offer couples with family histories of conditions such as Cystic Fibrosis, Sickle Cell Anemia, Huntington's Disease, Muscular Dystrophy, as well as many others; the opportunity to have unaffected children. However, this same technology may one day make it possible to select traits such as eye color, and hair color, etc., which makes many people very uncomfortable. Should we, as a society, now make laws that govern such technology when we are not even sure exactly what the technology will be? I do not have all the answers today, but I hope together we can all move forward with morally sound judgments that do not eliminate fantastic treatments such as PGD for genetic disease.
Recent public outrage and fascination with the "OctoMom," saga has refocused the spotlight on ethics in Assisted Reproductive Technologies (ART). Although the controversial story involving the California woman who recently gave birth to eight children is loaded with ethical missteps (should this patient have been treated at all, why did the doctor transfer so many embryos, who should take care of all these children, was this appropriate use of health care resources), the story has also allowed us to reexamine many other aspects of the field of ART from the viewpoints of patients, providers, society as a whole and, possibly, lawmakers.
When examining some of the ethical dilemmas we all face, it is important to be aware that advances in reproductive biology and techniques sometimes proceed faster than society can morally and legally grasp. Is it appropriate for society to make laws governing reproductive treatments today when a few years from now these laws may become obsolete? Take, for example, the number of embryos that should be transferred in In Vitro Fertilization (IVF). Ten years ago it was not uncommon for physicians to recommend transferring three to four embryos even in patients with a good prognosis for IVF. Today, our professional society, the American Society for Reproductive Medicine (ASRM), recommends transfer of no more than one or two in most cases. However, in older patients with poor prognosis, ASRM guidelines are flexible and allow physicians to transfer up to five embryos if the likely success rate for the patient is low. So if our lawmakers impose restrictions of no more than two embryos for transfer (as has been done in other countries), patients with poor prognosis will face an even greater struggle in trying to conceive.
If providers and patients do not act responsibly, however, society may feel obligated to step in with legal regulations. As providers we have to do a better job of "policing our own," when other providers are clearly acting outside the standard of care. Patients and providers together have to be responsible with health care resources when requesting specific treatments. This is true when deciding how many embryos to transfer in a case with a good prognosis, but this can be particularly difficult in a situation with a very poor prognosis.
More often than not, the dilemmas I face include whether to proceed with treatments when the chances of success appear to be extremely remote and other options, such as donor egg, adoption or stopping treatment. do not appear to be acceptable to patients. When providers and patients are at odds over the best course of action, it may be helpful to enlist the assistance of third party counselors. Physicians are learning that providing limited treatments, even in cases with a poor prognosis, may help a patient come to closure with their diagnosis and move forward. And all of us have anecdotes about the "one in a thousand" chance that resulted in the birth of a beautiful child. Still, it is most responsible if providers do not continue treatments over the long term for patients whose prognosis is extremely poor.
The field of Preimplantation Genetic Diagnosis (PGD) offers incredible potential for eliminating or reducing the chances of a child developing one of a host of inheritable disorders. We can offer couples with family histories of conditions such as Cystic Fibrosis, Sickle Cell Anemia, Huntington's Disease, Muscular Dystrophy, as well as many others; the opportunity to have unaffected children. However, this same technology may one day make it possible to select traits such as eye color, and hair color, etc., which makes many people very uncomfortable. Should we, as a society, now make laws that govern such technology when we are not even sure exactly what the technology will be? I do not have all the answers today, but I hope together we can all move forward with morally sound judgments that do not eliminate fantastic treatments such as PGD for genetic disease.
posted by Kathleen, Contributing Editor at
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