ASRM Ethics Committee Updates Two Opinions
Apr 24, 2019
Origin: ASRM Press Release
- Fertility treatment when the prognosis is very poor or futile
- Interests, obligations, and rights in gamete and embryo donation
The Ethics Committee of the American Society for Reproductive Medicine has updated two of its opinions: “Fertility treatment when the prognosis is very poor or futile” and “Interests, obligations, and rights in gamete and embryo donation.”
In “Fertility treatment when the prognosis is very poor of futile,” ASRM’s Ethics Committee advises on the way patients should be treated when their prospect of achieving a live birth is less than 1% (futile), or when they have a very poor prognosis, when the odds of a live birth are less than 5% per cycle. The Committee sets out the applicable ethical precepts, examines situations in which success is a remote prospect and clinicians may refuse treatment, and discusses ways to communicate bad news, minimize confusion and prevent conflicts.
The Committee recommends that clinics develop patient-centered policies to protect patients’ interests in doing everything they can to have a child and in making their own decisions, while also facilitating evidence-based assessments to support clinicians’ duty to provide beneficial care. This duty includes a responsibility to refrain from providing treatment which is almost certain to fail.
Patient-centered decision-making means that refusing treatment to protect a fertility center’s success rates is never justifiable, just as providing treatment that will not help the patient, but will result in financial gain for the provider, is never justified.
All decisions to refuse to initiate, or to continue, treatment should be made as part of a shared-decision-making process including physician and patients. This process of shared decision-making calls for the physician to periodically review the treatment plan with the patients.
While the provision of futile therapies is usually not considered ethical, the Committee notes that in some circumstances a patient may seek treatment for psychological benefit. In such cases, treatment may be provided after explicit education and discussion of values. When a treatment’s prospect of success is very poor, it is imperative that physicians clearly present the risks, benefits, and alternatives to their patients.
Egg donation, sperm donation, and embryo donation are widely-used in treatment for infertility and as a means for people who do not have an opposite-sex partner to have children. In “Interests, obligations, and rights in gamete and embryo donation,” ASRM’s Ethics Committee highlights the need for shared information in the consent process and identifies many of the medical, ethical, and social conflicts that may arise between and among the various participants and discusses possible resolutions.
The Committee finds that donors, recipients and clinic programs have ongoing moral relationships with each other that extend into the future, beyond the time of provision of gametes or embryos. As medical knowledge and technology, social norms, and the legal landscape evolve through the lifetimes of participants and their children, these relationships will likely need to be reevaluated. Clinics should make it clear, at the time of the donation, that promises of anonymity or future contact cannot be assured.
Because the foundational interests of all parties relate to health- physical and psychological- donors and recipients have, at minimum, an obligation to authorize the appropriate disclosure of non-identifying medical information.
In discussing the duties and information various parties owe, or choose to share with one another, the Committee advises that “open disclosure of medically relevant information to minimize the risk of serious adverse outcomes to all parties” is ethically required. They address the possibility that there is an ongoing responsibility of the donor to offspring to update his or her health history- recommending that donors continue to provide health information either to the clinic program or to another entity that can communicate it to the recipient family- and recognizing the possibility that, in some cases, the offspring’s health information may be of value to the donor and/or other recipient families and should be shared.
The Committee also discusses participants’ differing needs and preferences for information disclosure or privacy in matters apart from health information. They recommend that donors be encouraged to share other non-identifying information and allow for personal contact in the future if all parties agree. The Committee notes that perceptions of gamete and embryo donation and the relationships formed through the practice will continue to evolve and produce new ethical challenges. “Gamete and embryo donation is more than a transfer of gametes/embryos from one party to another. It is part of a method of family building that involves a complex interchange of emotions and psychological needs of donor, recipient, children, and, potentially, the participants’ extended family.”
ASRM President, Dr. Peter Schlegel remarked, “Both of these documents from the Ethics Committee emphasize the imperative of a patient-centered focus in reproductive medicine. Providing the best care for our patients requires more than coming up with the correct diagnosis of their disease states. We create a treatment path that addresses their infertility and, we hope, leads to a successful birth, but that also supports their personal vision of family.”
Ethics Committee of the American Society for Reproductive Medicine, Fertility treatment when the prognosis is very poor or futile: an Ethics Committee opinion, Fertility and Sterility, April 2019
Ethics Committee of the American Society for Reproductive Medicine, Interests, obligations, and rights in gamete and embryo donation: an Ethics Committee opinion, Fertility and Sterility, April 2019