Oncofertility

Advances in cancer treatment, particularly chemotherapeutics, are expected to lead to significant improvements in survival rates. While cancer incidence and death rates are decreasing, quality of life after cancer may be reduced due to early functional failure of the gonads and, consequently, infertility, resulting from either the disease itself or its treatment. This chapter introduces clinicians to the new field of oncofertility and the ethical issues it raises. It will consider the situation of young cancer patients facing reproductive consequences globally, the retrieval of gametes or gonadal tissue from minors, and the use of these tissues long term. The field of oncofertility is new, but ethical considerations regarding reproductive interventions are old. Understanding how we approach these issues on a personal level and from the public’s perspective will be assessed in this chapter.

Preimplantation Genetics

This chapter highlights the uses and ethical implications of preimplantation genetic testing and addresses the topic of liability as it applies to use of this technology to screen and select embryos for chromosomal abnormalities and genetic traits prior to implantation. When errors or wrongs occur, there may be significant medical, psychological, and economic implications for those individuals who sought preimplantation testing to avoid a genetic disease or to improve the chance of achieving pregnancy. Informed consent, wrongful birth, and wrongful life claims may be available to those who are harmed due to these errors.

Doing Harm

Under the guise of “protecting the unborn,” anti-abortion and related measures such as feticide laws are being used as the basis for arresting pregnant women and new mothers. It is often the case that the initial disclosure of information that led to the involvement of criminal law, child welfare, or other state authorities has been made by healthcare professionals, including doctors, nurses, and hospital social workers. Pregnant patients—like other patients—should expect that their medical health is a private matter and that healthcare provider–patient confidentiality will be respected. Such disclosures have legal, social, and public health consequences and frequently lead to interventions that are punitive and counterproductive, not protective. This chapter describes the ethical obligations of healthcare professionals, including their duty to advocate for the protection of confidential information and to work to change unjust practices, policies, and laws.

Professional Ethics in Obstetric Practice, Innovation, and Research

Obstetric clinical practice, innovation, and research should be guided by professional ethics in obstetrics. In this chapter, the authors distinguish professional medical ethics from medical ethics and bioethics. They set out an ethical framework for obstetrics based on the invention of professional medical ethics by two eighteenth-century physician-ethicists, John Gregory (1724–1773) and Thomas Percival (1740–1804). Professional ethics in obstetrics appeals to the ethical principles of beneficence and respect for autonomy and the ethical concept of the fetus as a patient. This framework is deployed to provide ethically justified, practical guidance about two ethical challenges in obstetric practice: the professionally responsible role of nondirective counseling of pregnant women about induced abortion and the professionally responsible role of directive counseling about planned home birth. This framework is also deployed to provide ethically justified, practical guidance about professionally responsible obstetric innovation and research for fetal benefit.

The Reproduction of Stratified (Assisted) Reproduction

This chapter considers epidemiological, historical, and ideological forces that constructed infertility as a “white” ailment and in vitro fertilization (IVF) as a treatment for the infertility of white professional women in their late 30s, 40s, and beyond. The author begins with a case from her own practice and then returns to IVF’s origins in the United States in the 1980s to show how in its practice and its technical details it reproduces race and class inequalities. Ultimately, the author argues that IVF grew out of an ideology of stratified reproduction, in which the fertility, reproduction, and motherhood of white, professional women was valued and that of poor women and women of color was not. While usual bioethical analyses of infertility treatment focus on the questions raised in sensational cases, here the author considers the race and class coding of infertility as a moral issue because, as she concludes, it is a question of whose lives matter.

Refusing to Force Treatment

Abortion is illegal after viability in most US states. However, the law permits, and ethics require, clinicians to respect pregnant people’s refusal of medical treatment throughout pregnancy and delivery even when it might prevent fetal demise or harm. This chapter explains why these seemingly contradictory standards are in fact consistent. It contextualizes pregnant people’s right to refuse medical intervention within the history of the legal and moral status of women, viable fetuses, and women pregnant with viable fetuses, and argues that the principle of justice breaks the tie that some people perceive between autonomy (of women) and beneficence (to fetuses), pushing the scales in favor of women. Finally, it offers ethically sound steps that obstetricians confronted with refusals should take to maximize care, and it considers the moral distress these unusual cases invariably invoke.

Ethical Issues in Oocyte Donation

Oocyte or gamete donation has allowed for the reproductive process to be broken down into its component parts (genetic mother, gestating mother, and rearing mother) and has introduced the inclusion of a third party for female infertility. Gamete donation has enabled previously infertile individuals to have children. This chapter reviews three ethical issues in gamete donation: the payment of donors, the medical and psychological well-being of donors after donation, and the issues related to information sharing between donors, parents and offspring.

Religiously Affiliated Healthcare Institutions

Religious hospitals represent a large and growing share of the United States healthcare system. As these networks expand their reach, patients may face additional threats to their ability to receive care based on their own values. Physicians practicing in religious institutions—especially in Catholic hospitals—have experienced moral distress when prevented from providing medical care in accordance with the patient’s best interest, and many are surprised by the scope of restrictions under Catholic directives. Patients need accurate information about the care they can expect to receive in religious institutions. However, many lack awareness and knowledge of how to identify religious institutions and services available. This chapter addresses the history, clinical conflicts, bioethical concerns, and empiric literature about reproductive care in US religious healthcare institutions, focusing on Catholic health systems.

Accessing Reproductive Technology in France

This chapter compares French and American approaches to assisted reproductive technologies (ART). These countries are a fascinating (and unexplored) mirror: the United States focuses on the individual, while France emphasizes the best interest of society as a whole. This results in an access to ART largely open in the United States, yet all costs are covered by patients, and an access strictly regulated by law in France (and quite restricted until recent changes), yet costs are fully financed. This chapter introduces readers to the legal framework of access to ART in France and its cultural foundations. It highlights the insistence on the “right to privacy” in the United States, a concept much less valued in France, and concludes with a discussion, using clinical cases, of the ethical issues underlying tensions between reproductive autonomy and public policymaking, which differ in both countries.

Introduction

Like all clinicians, reproductive healthcare providers face specialty-specific ethical questions. However, the first editor of this book, Dr. Julie Chor (JC), an obstetrician-gynecologist who also completed a Complex Family Planning Fellowship, has never found an ethics text that is tailored to the needs of practicing clinicians, students, and trainees in reproductive healthcare. This is an unfortunate gap in the literature because whether reproductive health providers come from obstetrics and gynecology, family medicine, pediatrics, or another field, they all must be able to identify and analyze complex ethical issues that lie at the crossroads of patient decision-making, scientific advancement, political controversy, government regulation, and profound moral considerations in the context of continually evolving medical, legal, and societal factors. To fill this gap, Dr. Chor invited co-editor Professor Katie Watson (KW), a bioethics professor and lawyer who focuses on reproductive ethics, to partner in creating the text that she has always longed to use but has never found while practicing and teaching in this complex milieu....