Ethics and Reproductive Medicine

From the beginning, in vitro fertilization (IVF) has been cloaked in sensation and controversy. Certainly Robert Edwards and Patrick Steptoe endured much criticism for their truly groundbreaking efforts along with the celebration of their phenomenal success. The interface of many essential truths held sacred by both the individual and society as a whole is exposed when creating life in the laboratory. It is therefore not surprising that assisted reproduction arouses often vastly differing opinions from scholars of the law, theology, philosophy, ethics, and medicine.

For nearly 25 years, I have had the privilege of practicing reproductive medicine. During this time, I have witnessed many examples of clinical work erupting into national and even international news stories. Occasionally awe-inspiring (e.g., the first donor egg/embryo pregnancies in 1984), many events were more like bombshells, fostering popular criticism and ridicule. I have been personally involved in a few of these controversies, and I can attest firsthand to the heavy weight of public opinion, which often is anything but supportive or favorable. Practitioners in our field should be keenly aware of the ramifications of promoting the sensational or holding press conferences after the fact rather than subjecting ideas first to the scrutiny of peer review. Headlines may bring quick attention and fame to individual physicians, but suspicion and distrust of our entire profession can follow a negative story and potentially last a long time.

Several cases in point follow. Who can soon forget the announcements of first the Frustaci and later the McCaughey septuplets; the 63-year-old menopausal mother and more recently two 70-year-old Indian women delivering babies through egg donation; Raelian sect claims of human cloning; and the “Octomom.” All of these calamities were widely broadcast on television and heavily reported in the written media. Pitched to a wary public, spun and respun in tabloid magazines, most of these happenings startled people by the very essence of their unnaturalness. Rarely explaining any possible medical motive or rationale behind why offenses occurred, or for that matter fostering appreciation of the science behind which each event actually did occur, the result was more likely to turn people off from any possible benefit and focus on the malfeasance of seemingly reckless action. Implicit in all criticism was the question of why physicians were willing to be active participants in what many consider to be a perversion, at worst, and an abuse, at best, of a technology developed to help infertile women have just one healthy child. Were principles of medical ethics adhered to in performing these cases? It seems more likely that individuals made decisions arbitrarily without proper consideration for the more far-reaching ramifications that such actions would have on both the patient and society at large.

The reality is that there is nothing “natural” about IVF, and scenarios beyond normal experience do become possible when men and women avail themselves of assisted reproductive technology. Thus, it is imperative that the axioms of medical ethics be applied and integrated into practice to avoid trespassing beyond what society will, or for that matter should, tolerate. If we as a profession fail to regulate ourselves in this regard, then I think it is safe to say that we should anticipate that outside agencies such as the state or federal governments will step in and do it for us. The American Society for Reproductive Medicine regularly publishes recommendations and guidelines for the ethical use of its technology. These doctrines are as important to read and understand as any Modern Trends article. When flagrant violations of stated principles occur, principles agreed upon by a consortium of our members, I believe that, collectively, our profession should stand up and address the trespassers publicly, and with just, punitive action. To do otherwise merely bolsters the charge that we are unable to police ourselves. So far at least, it seems the public's perception that we are impotent to act in this regard may be warranted.

The complexity of cases today, and the wide variety of requests for services, often dictates a multidisciplinary approach to reaching a reasonable consensus opinion on how best to manage certain scenarios. I have been fortunate in having the opportunity to present my more complicated requests to the ethics committee of a large medical center for discussion and guidance. I assure you that the collective opinion of 15 to 20 men and women, none of whom have a background in IVF and all of whom are well versed in the principles of medical ethics, has been invaluable in deciphering the layers of issues surrounding most of these cases. Without exception, these individuals have been able to assist me in coming up with a balanced and fair disposition for some of the most challenging circumstances. Certainly, it is true that most times the triage of everyday care is straightforward enough to manage without elaborate discussion. Yet, it is not always easy to know where the slippery slope lies. Consider, for example, the case of a lesbian woman wishing to establish a pregnancy using the egg of her sexual partner. Straightforward egg donation, right? What if she also wishes to use her brother's sperm so as to establish genetic linkage with herself? Feeling uncomfortable yet? What if the sperm were frozen for this use prior to his death? Certainly, this is not straightforward!

On a completely different note, I am concerned about commercial influences that affect our professional judgment. Pharmaceutical and medical technology companies, as well as medical practice enterprises, have increasingly integrated themselves into our clinical services. I think it is fair to say that discussions of money and ethics should not belong together. Yet, the juxtaposition of these two arenas occurs every day and in all of our practices. In the event you do not see the connection, consider the following. Do more than 100,000 Americans really need IVF each year? Certainly 25 years ago they did not. Do 60% of IVF patients genuinely require intracytoplasmic sperm injection? I recall taking care of patients prior to 1993 with the same problems of male factor infertility that typically got by rather well without employing it, at least so liberally. Should preimplantation genetic screening (PGS), sex selection, or egg freezing be considered standard of care procedures? Is “family balancing” a desirable end point or a euphemism for gendercide? Before we venture too far from the original purpose of our professional mission, the provision of fertility care to assist a woman in having a healthy baby, perhaps we need to reflect on the potential corruption of our services and our judgment by the financial enticements gained through practicing high-tech medicine. We indulge in multiple conflicts of interest every day as most centers (and typically their physician owners) receive compensation for their professional opinions, while ordering laboratory tests from laboratories from which they also profit and performing procedures on patients for which they are additionally paid, all the while supposedly not biased by any financial incentive. Such obvious conflicts of interest should be ethically unacceptable, but they are not labeled as such—at least not yet.

Further difficulties are created by a financially competitive industry. I believe the epidemic of multiple births is largely driven by the need to report pregnancy rates as high as possible to promote one's practice. The multiple-birth problem is probably much worse than we know, as multifetal pregnancy reduction has increased in practice. The Internet has accelerated this phenomenon as patients investigate the mandatory reporting of every practice without understanding what goes into accumulated pregnancy statistics. Individual Web sites are often woefully misleading, boasting rates that are hard to justify, and physicians all claiming to be “pioneers” of a frontier that has been well traversed by silent but deserved others. Competitive efforts to offer services different from neighboring establishments may be partly responsible for the disturbing trend of promoting ancillary techniques such as PGS, comparative genomic hybridization testing of embryos, or elective egg banking into mainstream practice.

I believe that consumerism threatens to change the direction of reproductive medicine. Pregnancy on demand is often at the core of some of our arduous decisions. Do the rights of the patient transcend the rights of the unborn, yet to be conceived, child? Should we not take the child, family and even society into consideration in making these delicate decisions? Many of the clinical challenges that are the most difficult to address bear directly on this question. Just because we can do something does not mean that we should. Likewise, just because a patient can afford to do something does not mean that we, as physicians, are obliged to go along with it. It is our authority and duty to make these choices that separate us as professionals from technicians.

I have enlisted the help of some outstanding colleagues to discuss many of these issues in this edition of Seminars. Many, but not all, are outside of our subspecialty and therefore have a very different view of our practice landscape. I welcome this view, as I have long appreciated and valued the opinions of the members of the Columbia University Medical Center Ethics Committee, who are not biased by the pressures inherent to running a daily practice and not likely to subjugate good judgment to please a demanding patient. The authors' topics are varied and may seem somewhat disconnected. Yet, in my 25 years of practice, I have encountered each of these issues many times, and it seems in today's environment with increasing frequency. The titles may seem obvious enough, but the substance of the discussions is anything but straightforward.

Lest you think that three decades of practice have left me feeling cynical and pessimistic, let me assure you that I am not. In fact, I have never been more optimistic or excited about the future of our field. The opportunities that lie ahead seem as limitless as life itself, and perhaps it is fair to say that as the specialty matures, assisted reproduction is not just about helping an infertile woman have a healthy baby after all. The marriage of laboratory embryology with genetics will inevitably help us to unravel the basic elements of our evolutionary past while helping us understand and improve our evolutionary future. To paraphrase a recent patient, who also happened to be a general surgery resident, “You have a really neat job. You really do!” Yes, I agree we really do. Not so much work as a vocation, we need to cherish and protect it as such.