EXECUTIVE SUMMARY

Fertility programs occasionally withhold services from prospective parents due to concerns about their child-rearing capacities. An updated position statement says that assessment should be:

• made jointly among members of the healthcare team;

• involve consultation with appropriate other professionals, including mental health specialists if indicated;

• based on clinics’ written procedures.


Fertility programs may withhold services from prospective parents due to valid concerns that they’ll be unable to care adequately for offspring, according to an updated position statement from the American Society of Reproductive Medicine (ASRM).1

“The provision of fertility services necessarily inserts a medical professional into a patient’s reproductive plan,” notes Judith Daar, JD, chair of ASRM’s ethics committee and visiting professor at UCLA School of Law and clinical professor of medicine at University of California, Irvine School of Medicine. This distinguishes this method of family formation from natural conception, in which the parties’ actions and decision-making occur in a private setting.

“Given this unique role, reproductive medicine specialists have an opportunity to observe and learn about their patients’ medical, social, and psychological histories,” says Daar, clinical professor of medicine at University of California, Irvine School of Medicine.

In rare cases, a provider becomes concerned that prospective parents are unable to provide minimally adequate or safe care for any resulting child. ASRM’s Ethics Committee supports a provider’s decision to withhold fertility treatment in an effort to avoid significant harm to a future child.

“Such decisions are ethically difficult,” says Daar. “They require balancing of a person’s right to reproduce against an unknown but likely risk that a child will suffer significant harm.”

In order to maximize the possibility this balance is correctly struck, the Ethics Committee recommends that any program’s assessment of a patient’s ability to care for a child or potential to cause harm to a child be made jointly among members of the healthcare team. If indicated, consultation with appropriate other professionals — including mental health specialists — also should occur.

The position statement also recommends that fertility clinics draft written procedures for making a determination to withhold services when there are concerns about the child-rearing capacities of prospective parents. “Such policies should be made available to patients,” says Daar. “Any determination to withhold treatment should be documented.”

Lisa Campo-Engelstein, PhD, associate professor at the Alden March Bioethics Institute at Albany (NY) Medical College, says it’s important to bear in mind that people who conceive naturally are not subject to anyone’s judgment as to whether they would be fit parents.

“Yet, providers of fertility services turn people away for all kinds of reasons. Some are well-grounded, and others not. We have different standards for people who are infertile,” says Campo-Engelstein.

Some argue that it’s inappropriate for healthcare providers to decide whether individuals will be competent parents or not, as the individuals are seeking a medical service. “If they oppose the patient’s lifestyle, that doesn’t seem like a well-grounded reason to turn someone away,” says Campo-Engelstein.

At the same time, healthcare providers have no ethical obligation to provide care they believe is inappropriate, unless it’s a life-threatening situation. “If they are concerned that the parent is not going to be able to care for the child, they might feel causally — and morally — responsible for any offspring that result,” says Campo-Engelstein.

While the patient’s right to refuse treatment is almost absolute in medicine, rights to receive treatment are more limited. “Doctors have autonomy, too, and can decide they are not going to treat you,” notes Campo-Engelstein.

Providers do have an obligation to refer patients elsewhere if the treatment is medically indicated but they are refusing the patient for religious or philosophical reasons. Depending on what these reasons are, it could raise ethical concerns. For instance, the provider’s view on which individuals make good parents might be biased or discriminatory. “I worry that this will reinforce the dominant cultural narrative of who makes good parents, which tend to be white, heterosexual, middle- or upper-class, able-bodied folks,” says Campo-Engelstein. “And that’s excluding a lot of other people.” Lesbian couples have reported being refused fertility services.2 Another well-known case involved two deaf women who wanted a deaf sperm donor, but were refused.3

If providers really believe their patient is incompetent to be a parent or could harm a future child, says Campo-Engelstein, one option might be to have patients undergo psychological counseling, so it’s not only the physician’s judgment involved.

An overarching ethical consideration, says Campo-Engelstein, is that providers don’t make this determination in other areas of medicine. For instance, some providers allow parents not to vaccinate their children or to refuse certain treatments. “But we draw the line with life-threatening conditions,” says Campo-Engelstein. “Where to draw the line [with fertility services] is a tough question.”

REFERENCES

1. Ethics Committee of the American Society for Reproductive Medicine. Child-rearing ability and the provision of fertility services: an ethics committee opinion. Fertil Steril 2017; 108(6):944-947.

2. Somashekhar S. Lesbians sue N.C. after being turned away from fertility clinic. The Washington Post: April 21, 2016. Available at: http://wapo.st/2BsspJu.

3. Spriggs M. Lesbian couple create a child who is deaf like them. Journ Med Ethics 2002; 28(5): 283.

SOURCES

• Lisa Campo-Engelstein, PhD, Associate Professor, Alden March Bioethics Institute, Department of Obstetrics & Gynecology, Albany (NY) Medical College. Phone: (518) 262-0239. Email: campoel@amc.edu.

• Judith Daar, JD, Visiting Professor, UCLA School of Law/Clinical Professor of Medicine, School of Medicine, University of California Irvine. Email: jdaar@law.whittier.edu.