Oncofertility, a fairly new but growing field, addresses the special reproductive needs of cancer patients — but guidelines for how to deal with ethical dilemmas have not yet been established.
“Clinicians are left to deal with these issues without much guidance,” says Ann Partridge, MD, MPH, professor of medicine and founder and director of the Program for Young Women with Breast Cancer at Harvard Medical School in Boston.
Partridge and colleagues authored a recent paper presenting the following three cases in which the patient wished to pursue reproductive assistance, but her decision was met with hesitance by her care team:1
- a patient who desired fertility treatments despite the danger in the context of her medical state;
- a patient who wished to have a child as a means of coping with her illness despite the risk to her and the fetus;
- a patient who had to weigh her cancer risk and treatments against the possibility of delivering a baby.
“Ideally, decisions are discussed as a multidisciplinary care team with the patient at the center,” says Partridge. “More tools for teams to rely on will help all parties approach the decisions with more knowledge and support.”
A central ethical challenge is how to recognize the personal significance of childbearing and patient autonomy, while still protecting and addressing the safety of the patient. “Clinicians have a duty to do no harm, which sometimes may be in conflict with patient wishes,” says Partridge.
There are many ethical considerations involved with preserving cancer patients’ fertility, says Lisa Campo-Engelstein, PhD, associate professor at the Alden March Bioethics Institute and Department of OB/GYN at Albany (NY) Medical College. The following are some scenarios that may require ethical deliberation:
• Patients may be unable to afford the cost of fertility preservation.
While cancer treatment is routinely covered by insurance companies, fertility preservation for cancer patients frequently is not included.
“Patients and their doctors are sometimes able to work together to ensure insurance coverage for fertility preservation, as otherwise this would be an expensive out-of-pocket cost for patients,” notes Campo-Engelstein.
• The fertility preservation treatment being offered may be established or experimental.
“There may be certain circumstances, such as age or lack of time, that exclude the possibility of pursuing established fertility preservation treatments,” says Campo-Engelstein.
If patients’ only options are experimental methods, they need to be made aware of this fact, as well as all the potential risks and benefits associated with experimental treatments, she explains. This ensures proper informed consent.
• The patient may be a minor.
“As with all procedures involving minors, various ethical issues arise, such as whether the patient is able to provide consent or assent,” says Campo-Engelstein.
Established fertility preservation treatments aren’t always possible, depending on the patient’s physical maturity. “Instead, they may have to rely upon experimental fertility preservation treatments,” says Campo-Engelstein.
• Healthcare professionals aren’t always comfortable offering the patient fertility preservation, based on the patient’s diagnosis and prognosis.
A patient may have an extremely poor prognosis, or fertility preservation may be contraindicated given the type of cancer she has.
Despite this, fertility preservation may be very important to the patient, says Campo-Engelstein: “She may want to pursue it despite her prognosis and the risk it may pose to herself.”
- Walsh SK, Ginsburg ES, Lehmann LS, et al. Oncofertility: Fertile ground for conflict between patient autonomy and medical values. Oncologist 2017 Apr 13. pii: theoncologist.2016-0373. doi: 10.1634/theoncologist.2016-0373. [Epub ahead of print]
- Lisa Campo-Engelstein, PhD, Associate Professor, Alden March Bioethics Institute and Department of OB/GYN, Albany (NY) Medical College. Phone: (518) 262-0239. Fax: (518) 262-6856. Email: firstname.lastname@example.org.
- Ann Partridge, MD, MPH, Professor of Medicine, Harvard Medical School, Boston. Phone: (617) 632-3800. Fax: (617) 632-1930. Email: Ann_Partridge@dfci.harvard.edu.