Topic: Reproductive Medicine
January 14, 2016 | Posted By Jane Jankowski, DPS, LMSW

“Of all the ways to be wounded,” regrets Jake from Ernest Hemingway’s novel The Sun Also Rises, setting the stage for a narrative which implies the male character’s war injury to his genitals rendering him irreversibly and torturously impotent. Recently, the NY Times reported that research on penis transplants would offer a possible treatment option for men who have suffered injury to the groin in war or other trauma (www.nytimes.com-heal-troops).  To attempt to restore function and procreative ability cadaveric penis transplants will be undertaken as an experimental procedure. As noted in the article cited above, consent from donor’s family would be secured as with any organ donation. While some may find such surgical interventions to be less compelling than other transplants which provide life- saving organs (heart, lung, kidney, liver, pancreas) transplanting reproductive organs offers important benefits to patients.   

Uterine transplants have been discussed in the media recently, and seem to hold promise as these transplants have been done successfully in Sweden(www.nytimes.com-uterus-transplants ). Women born without a uterus may soon be able to receive a cadaveric uterus in the US. Unlike penis transplants which rely on exclusively cadaveric donation, live donation has been performed for uterine transplants in Sweden, and in time may also be available for women in the US.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

December 29, 2015 | Posted By Claire Horner, JD, MA

“It is a disturbing consequence of modern biological technology that the fate of the nascent human life, which the Embryos in this case represent, must be determined in a court by reference to cold legal principles.”  Findley v. Lee, No. FDI-13-780539, 4 (Cal. Tentative Ruling Filed Nov. 18, 2015).

On November 18, 2015, the Superior Court of California issued a Tentative Decision and Proposed Statement of Decision holding that five embryos that were created and cryopreserved by a husband and wife, now divorced, must be destroyed in accordance with the agreement signed by the parties prior to beginning IVF.  According to the Court, the agreement contained, among others, a provision determining in advance the agreed-upon disposition of any remaining embryos in the event of divorce.  For this provision, both spouses initialed “thaw and discard.”  This “contractual approach” has been adopted by several jurisdictions that have had occasion to determine disposition of embryos in divorce.  In this analysis, courts will enforce an agreement signed by the parties prior to IVF as evidence of their intentions at the outset of the process.  

Courts in some states have decided such cases using different approaches.  The Constitutional rights approach (or balancing approach) looks at the interests of the parties, evaluating and balancing their respective rights, which seems to result in a comparison of the right to procreate and the right to avoid procreation.  This paradigm, in practice, has led courts to conclude that the right to avoid procreation typically prevails.  The contemporaneous mutual consent approach, on the other hand, attempts to reconcile the contractual approach with the current wishes of the parties by holding that pre-IVF agreements are valid and enforceable unless and until one of the parties changes his or her mind.  While this approach appears to recognize contracts, in practice a contract is disregarded where there is disagreement, and the embryos remain frozen until a mutual decision can be reached.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

December 24, 2015 | Posted By Paul Burcher, MD, PhD

I was surprised to read recently in the New York Times that a woman has undergone a cesarean section despite her refusal to consent to the procedure.  While the details of the case are not entirely clear in the article, so I do not want what follows to be understood as a specific comment on this case, my surprise arises because I thought the ethics of refusal of consent were not in dispute.  The American College of Obstetrics and Gynecology has taken a clear position of this: it is not justifiable to perform surgery on a patient with decisional capacity without her consent. ACOG’s committee opinion, “Maternal Decision Making, Ethics, and the Law,” strongly discourages even attempting to seek a court order for treatment when a pregnant woman refuses cesarean section, and concludes with a statement that:

Pregnant women's autonomous decisions should be respected. Concerns about the impact of maternal decisions on fetal well-being should be discussed in the context of medical evidence and   understood within the context of each woman's broad social network, cultural beliefs, and values. In the absence of extraordinary circumstances, circumstances that, in fact, the Committee on Ethicscannot currently imagine, judicial authority should not   be used to implement treatment regimens aimed at protecting the fetus, for such actions violate the pregnant woman's autonomy. 

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

December 18, 2015 | Posted By Lisa Campo-Engelstein, PhD
Last month I attended the Oncofertility Consortium conference and gave a talk titled “Ethical Considerations of Fertility Preservation in Adolescents.” The goals of this talk were to describe the common ethical considerations of fertility preservation (FP) for adolescent cancer patients and to explore the different medical and social considerations for adolescent females and males due to sex and gender.

Like any medical intervention for the adolescent population, there is the question of whether adolescents are able to assent or consent to FP. Should the decision to pursue FP rest in the hands of the adolescent or the adolescent’s parents/guardians? On the one hand, adolescents may choose to forgo FP because they do not understand the value of their fertility may have them later especially since, at their age, they are bombarded with messages about avoiding pregnancy. On the other hand, adolescents may feel pushed to undergo FP due to parental pressure (e.g. their parents/guardians want to be grandparents in the future).

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.
November 16, 2015 | Posted By Lisa Campo-Engelstein, PhD

As I have discussed in previous blogs, fertility preservation for cancer patients can be quite expensive and insurance companies do not cover it. Fertility preservation for cancer patients is excluded because cancer patients are generally not currently infertile, but instead they have anticipated infertility due to their cancer treatment. I have argued that insurance companies should cover fertility preservation because it is not ethically different from other treatments for iatrogenic conditions currently covered for cancer patients. For example, insurance covers other quality of life treatments such as wigs for alopecia and breast reconstructive surgery following mastectomy. Like these treatments, fertility preservation is not lifesaving, but can significantly improve quality of life, as infertility can lead to depression, anxiety, and distress. Since much of medicine today focuses on improving quality of life for people with non-life threatening conditions (e.g. poor vision, back pain, seasonal allergies, sexual dysfunction, etc.), it does not make sense to exclude fertility preservation on the basis that it is not life saving.  

However, some question whether fertility preservation for cancer patients is a just use of finite health care resources based on economic reasons. One cycle of IVF is on average $12,400 and estimates for ovarian tissue cryopreservation range from $5,000-$30,000. Furthermore, annual storage fees for frozen gametes and embryos can run up to hundreds of dollars a year While ART are very expensive on the individual level, they are not on the broader social level: in fact, they account for only 0.06% of the total health care expenditure in the United States. The lack of insurance coverage for fertility preservation raises the justice concern that only certain individuals will be able to utilize it, namely those who can pay out-of-pocket for it. These individuals are most likely from the same demographic as the primary users of ART: white, educated, and middle- and upper-class. While 14 states currently have mandates requiring insurance companies to cover some types infertility treatments, there are no similar laws for fertility preservation. 

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

November 11, 2015 | Posted By Paul Burcher, MD, PhD

A couple of weeks ago I was I was the faculty attending on Labor and Delivery. We were inducing a woman with severe pre-eclampsia and an IUGR fetus. Things went well until she was five centimeters dilated, at which point the fetal tracing went rapidly from category one to category three (reassuring to really bad). I quickly explained the situation to the patient with a resident and a nurse in the room. She heard the reasons I was recommending a cesarean section, a brief discussion of its risks, and an even briefer discussion of the alternatives (continue labor placing the fetus at risk of permanent injury or death). She had no questions, and since she had already signed a cesarean consent at the beginning of the induction, we proceeded to the operating room to perform a cesarean.  She needed general anesthesia because her platelets were low, so it was too risky to give her a spinal anesthetic. During the induction but before intubation, the circulating nurse announced that she couldn’t find the “informed consent” and that we could not proceed. My response involved a reference to male cattle manure, and the comment that informed consent had just happened and that she had witnessed it herself. The anesthesiologist agreed, and the cesarean section occurred without delay.

This case exemplifies the ambiguity around “informed consent.”  The nurse was referring to a document, a signed piece of paper; I was referencing a conversation, a process involving sharing information and answering questions. From a legal perspective, informed consent would seem to represent the document, whereas from an ethical perspective it is the process, not the paper that embodies informed consent.  Of course, ultimately, both have a role to play, and in the case of a significant procedure it is best to have both sides of this informed consent coin documented.  But what I would like to suggest is that the signed document represents an artifact—a physical symbol that two parties agree that the real nature of informed consent has been fulfilled.  The piece of paper is derivative, and a signed document that lacks the ethical underpinning of a complete and valid consent discussion is meaningless. A lawyer would probably give a slightly different answer, but this is an ethics blog, not a discussion of medical malpractice.  

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

October 6, 2015 | Posted By Claire Horner, JD, MA

A Catholic hospital came under fire recently for stating that it would not permit doctors to perform a tubal ligation during a c-section scheduled for October.  According to news reports (including anarticle written by the patient herself), the pregnant patient has a brain tumor, and her doctor have advised her that another pregnancy could be life-threatening.  Her doctor has recommended that she have a tubal ligation at the time of her c-section.  While my knowledge about this hospital, this case, and the participants is limited to what has been reported in the media, it raises an interesting question: in our pluralistic society, where conscientious objection is respected while maintaining a patient’s right to a certain standard of care, is it ethical to allow a religiously-affiliated health care institution to refuse to provide certain treatments it finds morally objectionable?

As background, the Catholic Church has historically been outspoken on bioethical issues and has a strong and robust bioethical teaching.  Catholic hospitals are governed by the Ethical and Religious Directives for Catholic Health Care Services (ERDs), a document promulgated by the United States Conference of Catholic Bishops (USCCB) that clearly articulates the bioethical policies that must be followed in a health care institution based on the Church’s moral teachings.  It explains the Church’s teaching against direct sterilization as a method of birth control based on the principle of double effect.  “Direct sterilization of either men or women, whether permanent or temporary, is not permitted in a Catholic health care institution.  Procedures that induce sterility are permitted when their direct effect is the cure or alleviation of a present and serious pathology and a simpler treatment is not available.” (Directive 53).  In other words, if the sterilization procedure directly treats a pathology, it is licit; if it is used as a form of birth control to prevent a pregnancy, even if that pregnancy would be life-threatening, it is not licit.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

October 1, 2015 | Posted By Lisa Campo-Engelstein, PhD

Savior siblings are children who are born to provide HLA compatible body parts, typically umbilical cord blood to be used for bone marrow transplantation, in order to save the life of their older sibling. They are created using IVF so that the embryos can be screened in order to find and implant one that is a match to the existing child. The first savior sibling, Adam Nash, was born in the US was born in 2000. Lisa and Jack Nash decided to create a savior sibling after their doctor suggested it might be the best option for a cure for their daughter Molly, who was born with a severe type of Fanconi anemia. Immediately after Adam was born, Molly received a bone marrow transplant using the umbilical cord blood from her brother. The notion of savior siblings gained more attention with Jodi Picoult’s book My Sister’s Keeper and the movie based on the book. In contrast to Adam Nash, the savior sibling in the book and movie is expected to continue giving bodily to her sister throughout her childhood, including organ transplantation, rather than one time umbilical cord donation.

Is it ethical for parents to create a savior sibling? Some argue that the parents’ intention plays a role in considering whether it is ethical to create a savior sibling. If the parents were not planning on having any more children and they are the having the savior sibling only for the sake of the older child, then there is the concern of using the savior sibling as a means to an end. If the parents were planning on having more children, then some claim that the savior sibling is wanted for her/his own sake and is not being created for just one purpose (i.e. to save the older child).

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

September 14, 2015 | Posted By Lisa Campo-Engelstein, PhD

In some countries where there is a strong preference for sons due to cultural and religious reasons, women sometimes choose to have an abortion after learning the sex of the fetus they carry is female, which is often referred to as sex selection abortion. For example, sex selection abortion is common in India and has increased significantly in the couple of last decades, especially for pregnancies following a firstborn daughter. The prevalence of sex selection abortion is also common in China, often referred to as the “missing girls of China” phenomenon, and is due to a similar cultural preference for sons as well as the One Child Policy.

Given the strong pressure women are under to have sons, is ethical for them to have sex selection abortions? Some point out that it may not be women’s authentic choice that is leading them to abort female fetuses but rather familial pressure from their husband and other family members as well as broader social pressure. In these situations, paternalistic approaches may be more justifiable in order to protect women from oppressive social forces that may coerce them into having sex selection abortion. From a justice perspective, outlawing sex selection abortion sends the message that sex discrimination is wrong, seeks to protect female fetuses, and attempts to ensure a balanced birth ratio between females and males.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

July 23, 2015 | Posted By Lisa Campo-Engelstein, PhD

Planned Parenthood recently made national news because an anti-abortion group released an undercover video showing two people posing as fetal tissue recruiters interviewing Dr. Deborah Nucatola, the senior director of medical services of Planned Parenthood. The interview was cropped down into an eight minute clip in which Dr. Nucatola seems to be suggesting that Planned Parenthood sells fetal tissue for profit. Planned Parenthood has responded to the video saying that it is heavily edited and that they do not sell fetal tissue. They do, however, donate fetal tissue with women’s explicit consent and they sometimes receive a small amount of money – in the video Dr. Nucatola says it is typically between $30-100 – that covers transportation of the fetal tissue.

This story made national news because the idea of selling fetal tissue for profit without women’s consent is horrifying. Yet, once we uncover the facts here, this story is much less troubling than it originally seems. One concern the undercover video raises is of selling fetal tissue. It is illegal in the US to sell human and fetal organs and tissue. However, it is not only legal, but also laudable to altruistically donate organs and tissue. Because there is such a strong need for organs and tissue for patients waiting for transportation and for scientific research, there are various campaigns to get people to sign up to be cadaveric organ donors, to donate blood, and to be live kidney donors.  In the US, organ donation is opt-in only, meaning it is completely voluntary and people are under no ethical obligation to donate. Likewise, women who have abortions are under no ethical obligation to donate fetal tissue and typically the fetal tissue is discarded. Women who choose to donate fetal tissue for scientific research are acting altruistically because there are choosing to further scientific research, which could help others in the future.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

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BIOETHICS TODAY is the blog of the Alden March Bioethics Institute, presenting topical and timely commentary on issues, trends, and breaking news in the broad arena of bioethics. BIOETHICS TODAY presents interviews, opinion pieces, and ongoing articles on health care policy, end-of-life decision making, emerging issues in genetics and genomics, procreative liberty and reproductive health, ethics in clinical trials, medicine and the media, distributive justice and health care delivery in developing nations, and the intersection of environmental conservation and bioethics.
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