KEY POINTS■ Although clinicians are ethically required to treat all patients in need of medical attention, many providers already impose medical restrictions on access to infertility treatments. Some providers feel that their obligation ends at assessing medical fitness. Others, while acknowledging their responsibility to assess parental fitness, feel ill-prepared to do so.
■ Recommendations from the American Society of Reproductive Medicine (ASRM) include withholding services if there is evidence that the patients are unable to provide adequate care of the child. The ASRM further recommends that assessments of the evidence be made jointly by members of the fertility program involved and that the basis for making these determinations be set down in writing.
■ Current recommendations conclude that fertility services should not be denied to unmarried or homosexual persons or to those infected with HIV. Nevertheless, most fertility clinics are private organizations that can restrict access to services based on their own criteria. Approximately 97% of registered fertility clinics do not offer services to HIV-infected patients.
■ Perhaps the best approach is for each provider to decide on a case-by-case basis before offering infertility treatment which patients he or she considers good candidates and which patients should undergo more intensive psychological testing, counseling, or evaluation.
Infertility affects approximately 15% of American couples.
1 With advances in infertility technologies, more patients are seeking medical treatment in order to achieve pregnancy. As a result, large centers devoted solely to treating infertility have been established in the United States and around the world.
Most complex infertility treatments are provided by specialists who are often located in specialized centers. However, patients may access some forms of infertility treatment in small obstetric practices or even through physician practices in general fields, such as family medicine. Treatments range from ovulation induction with oral clomiphene (Clomid, Serophene) to donor treatments (such as artificial insemination, oocyte or embryo donation) to intracytoplasmic sperm injection, in vitro fertilization, gamete intrafallopian transfer, and zygote intrafallopian transfer.
THE ETHICAL DEBATE
The widespread availability of infertility treatments has led to an ethical debate on reproductive rights. The debate comprises cultural, legal, and professional aspects.
The current cultural philosophy in the United States is that childbearing is a right.2 Infertility is a medical condition, and therefore, patients feel that the medical community has an obligation to treat them with whatever means necessary to overcome their infertility. Based on these societal standards, some physicians feel that they are "playing God" if they deny these services to patients.3
From a legal standpoint, refusing to provide fertility services to patients can be viewed as patient abandonment or discrimination. Clinicians must be careful to avoid the perception of abandonment by providing timely notice that they wish to dissolve the patient-provider relationship. In terms of discrimination, the denial of services would need to be based on factual information and not on poorly substantiated suspicions, race, religion, ethnicity, stereotypes, or disabilities.4 Another potential legal implication centers on liability for the provider who aids in the conception of a child when the provider knows that child is at risk for harm.
In addition to considering the cultural and legal aspects of providing fertility services to patients, providers also must examine their professional obligations. Although clinicians are ethically required to treat all patients in need of medical attention, provider autonomy allows them to assert their own morals, values, and beliefs when offering services to patients. Many providers already impose medical restrictions on access to infertility treatments.5 These restrictions include denying certain services based on advanced maternal age or medical conditions that would significantly increase the risk of maternal and fetal morbidity and mortality.
Some providers feel that their obligation ends at assessing medical fitness. Others, while acknowledging their responsibility to assess parental fitness, feel ill-prepared to take on the task.6 Simply refusing to address the issue of parental fitness because doing so is difficult or subject to error does not make such refusal acceptable, however.6