Restricting Access to ART on the Basis of Criminal Record : An Ethical Analysis of a State-Enforced "Presumption Against Treatment" With Regard to Assisted Reproductive Technologies

A study of the experience of Norwegian IVF physicians in evaluating the parenting capacity of patients

RESEARCH QUESTION

How do Norwegian fertility doctors assess the parenting capacity of applicants, and how do they experience and evaluate the assessment practice?

DESIGN

Qualitative interview study with 14 Norwegian fertility doctors. Interviews were analysed with systematic text condensation, a qualitative analysis framework.

RESULTS

Norwegian fertility doctors deem parenting capacity assessments of applicants to be straightforward and simple in most cases. Yet, some cases of doubt pose difficulties. Physicians can then draw on resources such as colleagues, physicians from other specialties who know the patient and patient records. All the participating physicians agreed with the principle of parenting capacity assessment for patients seeking fertility treatment. The assessment enabled physicians to refuse patients whom they thought should definitely not have responsibility for children. The physicians' main argument was their own felt responsibility for the future child. Even though assessments could be challenging, the participants all thought of themselves as competent to perform them. Indeed, some thought that delegating the assessments would imply abdicating a responsibility that was properly theirs. Although national guidelines might aid decision-making, the physicians would not want guidelines to curtail the significant discretion that they exercised.

CONCLUSIONS

Whether societies should assess applicants' capacity for parenthood before fertility treatment is an ethical and political question. Although sometimes a difficult task, Norwegian fertility doctors see it as important, and as something they are competent and suited to undertake.

Access to infertility evaluation and treatment in two public fertility clinics and the reasons for withholding it: a prospective survey cohort study of healthcare professionals

OBJECTIVES

Study the proportion of patients affected by involuntary childlessness who are denied fertility treatment and the reasons behind this in a publicly funded healthcare system.

DESIGN

Survey study using prospectively collected information by healthcare professionals.

SETTING

Two university-affiliated fertility clinics in Sweden.

PARTICIPANTS

Single women and couples in heterosexual and homosexual relationships seeking fertility evaluation and treatment between November 2017 and April 2018 (943 individual cases).

PRIMARY AND SECONDARY OUTCOME MEASURES

Number and proportion of individuals who were either denied, delayed or granted fertility treatment directly. Furthermore, the reasons behind delaying or completely withholding treatment.

RESULTS

The majority of those seeking evaluation were heterosexual couples (75%), while 14% were single women and 7.5% were same-sex couples. The great majority of those undergoing evaluation were granted treatment either directly (85%) or after in-depth evaluation (7.5%), while 7.5% were denied treatment. Among those who were denied treatment, there were a greater proportion of single women and couples seeking treatment with donated gametes. Among heterosexual couples, gamete origin was not associated with treatment refusal. Although age did not differ between those granted and denied treatment, a higher body mass index (in both recipient and partner, when applicable) was observed among those being refused treatment. Fertility specialists in Sweden focused their assessment on parental factors that may indirectly entail a risk of harm to the future child, such as medical and psychiatric conditions of the individuals involved, their financial constraints and other social reasons, substance abuse and female obesity.

CONCLUSION

Being single or receiving treatment with donated gametes can both be reasons for withholding fertility treatment. Although difficult to operationalise, parenting assessment in Sweden is employed interchangeably in treatments with donated gametes (legally mandated assessment) and even autologous gametes (non-legally mandated assessment)-making evident a need for clear official policy guidelines regulating these assessments and the provision of treatment.

Dealing with treatment and transfer requests: how PGD-professionals discuss ethical challenges arising in everyday practice

How do professionals working in pre-implantation genetic diagnosis (PGD) reflect upon their decision making with regard to ethical challenges arising in everyday practice? Two focus group discussions were held with staff of reproductive genetic clinics: one in Utrecht (The Netherlands) with PGD-professionals from Dutch PGD-centres and one in Prague (Czech Republic) with PGD-professionals working in centres in different European countries. Both meetings consisted of two parts, exploring participants' views regarding (1) treatment requests for conditions that may not fulfill traditional indications criteria for PGD, and (2) treatment and transfer requests involving welfare-of-the-child considerations. There was general support for the view that people who come for PGD will have their own good reasons to consider the condition they wish to avoid as serious. But whereas PGD-professionals in the international group tended to stress the applicants' legal right to eventually have the treatment they want (whatever the views of the professional), participants in the Dutch group sketched a picture of shared decision-making, where professionals would go ahead with treatment in cases where they are able to understand the reasonableness of the request in the light of the couple's reproductive history or family experience. In the international focus group there was little support for guidance stating that welfare-of-the child considerations should be taken into account. This was different in the Dutch focus group, where shared decision-making also had the role of reassuring professionals that applicants had adequately considered possible implications for the welfare of the child.

Infertilitism: unjustified discrimination of assisted reproduction patients

Current law in Victoria, Australia requires that all prospective assisted reproduction patients provide a criminal background check and child protection order check prior to being eligible for treatment. These presumptions against treatment stipulated in the Assisted Reproductive Treatment Act ( http://www.legislation.vic.gov.au/domino/web_notes/ldms/pubstatbook.nsf/f932b66241ecf1b7ca256e92000e23be/3ADFC9FBA2C0F526CA25751C0020E494/$FILE/08-076a.pdf , 2008) are discriminatory against all people that are infertile. Requiring assistance in founding a family says nothing about whether someone will be a minimally decent parent to their (future) child. The most plausible justifications for this differential treatment of family builders that require assistance are unsound. The wellbeing of the resulting child is something that the prospective patient(s) should be presumed to have at heart, as this is the default assumption with other kinds of family builders that do not require assistance. That assisted reproduction treatment is publicly funded does not mean that the state is thereby justified in putting moral conditions on access to treatment. As we should not accept discriminatory laws, especially about practices that are of fundamental importance to the lives of citizens, the presumptions against treatment stipulated in ARTA should be eradicated.