Medicine in the marketplace: clinician and patient views on commercial influences on assisted reproductive technology

RESEARCH QUESTION

What are the views and experiences of patient and expert stakeholders on the positive and negative impacts of commercial influences on the provision of assisted reproductive technology (ART) services, and what are their suggestions for governance reforms?

DESIGN

Semi-structured interviews were conducted with 31 ART industry experts from across Australia and New Zealand and 25 patients undergoing ART from metropolitan and regional Australia, between September 2020 and September 2021. Data were analysed using thematic analysis.

RESULTS

Expert and patient participants considered that commercial forces influence the provision of ART in a number of positive ways - increasing sustainability, ensuring consistency in standards and providing patients with greater choice. Participants also considered commercial forces to have a number of negative impacts, including increased costs to government and patients; the excessive use of interventions that lack sufficient evidence to be considered part of standard care; inadequately informed consent (particularly with regard to financial information); and threats to patient-provider relationships and patient-centred care. Participants varied in whether they believed that professional self-regulation is sufficient. While recognizing the benefits of commercial investment in healthcare, many considered that regulatory reforms, as well as organizational cultural initiatives, are needed as means to ensure the primacy of patient well-being.

CONCLUSIONS

The views expressed in this study should be systematically and critically examined to derive insights into how best to govern ART. These insights may also inform the design and delivery of other types of healthcare that are provided in the private sector.

Providing Lactation Care Following Stillbirth, Neonatal and Infant Death: Learning from Bereaved Parents

Objective: The study aimed to identify how, from the perspective of bereaved parents, hospital-based health professionals can better meet their lactation care needs. Methods: In-depth interviews were conducted with 17 mothers and 7 fathers bereaved by stillbirth, neonatal death, or older infant death. Participants were recruited from three large hospitals in Eastern Australia including two with human milk banks. Qualitative thematic data analysis identified bereaved parents' lactation experiences, needs, and how parents wanted lactation care to be provided. Results: Participants experienced lactation after infant death as hard and challenging, while at the same time they received limited lactation care. The negative impact of lactation, however, could be mediated by anticipatory guidance, assistance to make sense of lactation, support to make decisions from available lactation and breast milk management options, and support with breast care for as long as required. Bereaved parents explained lactation care was best provided by health professionals they had come to know and trust rather than by a particular professional role. Care should be provided with compassion, in a manner respectful of individual circumstances, inclusive of partners, and supplemented by quality written information. When bereaved parents felt supported to manage their lactation in a manner consistent with their unique needs, lactation for some could have a positive impact on grief. Conclusion: Bereaved parents have demonstrated that comprehensive lactation care is critical to their health and well-being. Such care should be more fully incorporated into hospital-based bereavement care policies and practices.

Mothers, milk and mourning: The meanings of breast milk after loss of an infant

Breast milk is a highly valued substance, immunologically and nutritionally, which also signifies maternal care and love for the infant. This intersection of biological and cultural qualities confers breast milk with complex meanings, which necessarily shape the experience of breastfeeding. Our research, investigating the experience of lactation after the loss of an infant, casts a novel light on these meanings. This article analyses the experience of 17 Australian bereaved mothers and 114 health professionals charged with their care. We find that while all the mothers found post-loss lactation emotionally painful, many also found redemptive meaning in their milk-production, as a bond with the lost child, as confirmation of their maternal competence and as a life giving substance that they could donate to other needy infants. These complex meanings and positive connotations were at odds with hospital cultures that regard post-loss lactation as valueless and best dealt with through medical suppression, despite the more complex insights of individual health-care professions.

Supporting Aboriginal and Torres Strait Islander Families to Stay Together from the Start (SAFeST Start): Urgent call to action to address crisis in infant removals

Reducing the rate of over-representation of Aboriginal and Torres Strait Islander children in out-of-home care (OOHC) is a key Closing the Gap target committed to by all Australian governments. Current strategies are failing. The "gap" is widening, with the rate of Aboriginal and Torres Strait Islander children in OOHC at 30 June 2020 being 11 times that of non-Indigenous children. Approximately, one in five Aboriginal and Torres Strait Islander children entering OOHC each year are younger than one year. These figures represent compounding intergenerational trauma and institutional harm to Aboriginal and Torres Strait Islander families and communities. This article outlines systemic failures to address the needs of Aboriginal and Torres Strait Islander parents during pregnancy and following birth, causing cumulative harm and trauma to families, communities and cultures. Major reform to child and family notification and service systems, and significant investment to address this crisis, is urgently needed. The Family Matters Building Blocks and five elements of the Aboriginal and Torres Strait Islander Child Placement Principle (Prevention, Participation, Partnership, Placement and Connection) provide a transformative foundation to address historical, institutional, well-being and socioeconomic drivers of current catastrophic trajectories. The time for action is now.

Mapping Hospital-Based Lactation Care Provided to Bereaved Mothers: A Basis for Quality Improvement

Objective: The study aimed to identify and map the factors that shape the delivery of hospital-based lactation care for bereaved mothers to inform quality improvement initiatives targeting hospital-based lactation care. Methods: Focus groups and interviews were conducted at three large hospitals in Australia with 113 health professionals including obstetricians, neonatologists, midwives, neonatal nurses, lactation consultants, social workers or pastoral care workers, Human Milk Bank (HMB) staff, and perinatal bereavement nurses. Thematic and interactional data analysis identified the nature, scope, and pattern of bereavement lactation care. Results: A bereaved lactation care pathway was generated from health professionals' reports. Bereaved lactation care, if provided, was limited to brief encounters aimed at facilitating lactation suppression. The type of lactation care offered, and any exploration of the variable biopsychosocial significance of lactation after infant death, was conditional on (i) availability of health professionals with suitable awareness, knowledge, capacity, confidence, and comfort to discuss lactation; (ii) hospital culture and mode of suppression primarily practiced; (iii) mother's breast milk being visible to hospital staff; (iv) mother expressing interest in expanded lactation management options; (v) availability of, and eligibility to, donate to a HMB; and (vi) support beyond the hospital setting being facilitated. Conclusion: Mothers should be presented with the full array of lactation management options available after stillbirth or infant death. Inclusion of evidence-based, biopsychosocial and patient-centered approaches to lactation care is urgently required in health professionals' bereavement training and in the policies of hospitals and HMBs.

Unconventional Practice, "Innovative" Interventions and the National Law

This column explores a recent health profession disciplinary case which throws light on the problems of unconventional interventions by medical practitioners under the Health Practitioner Regulation National Law Act 2009 (Qld). The case involved "innovative" practices which were later found to have been scientifically unsupported, dangerous to patients and grounds for cancelling the health practitioner's registration. This column looks at common features of these kinds of cases in Australia and then examines recent attempts by the Medical Board of Australia to draft policy guidance around the use of unconventional practice in medicine. This column concludes with a number of changes to improve the effectiveness of the proposed policy.

Lactation after infant death: an analysis of Australian healthcare agencies' online health information

Lactation is a potent signifier of maternal love and care commonly associated with early motherhood and infant survival. It is common, however, for bereaved mothers who have recently undergone miscarriage, stillbirth or infant death to produce breastmilk. Drawing on a critical feminist lens that seeks to understand how maternal subjectivities and lactation norms are constructed through public and reproductive health information, this article tests whether lactation management options after stillbirth and infant death are comprehensively covered in Australia's health organisations' online information. A qualitative directed content analysis was conducted to critique the information provided on 21 Australian websites. Information extracted from websites was compared to a 'best-practice' Lactation After Infant Death (AID) Framework developed by the research team for the review. We found a notable absence of comprehensive lactation management information targeted directly to bereaved mothers. Moreover, the most common lactation option presented for women without a living infant was lactation suppression. This dearth of appropriate and comprehensive lactation information curtails maternal subjectivies and diverse lactation practices and further isolates women dealing with the painful contradictions of lactation after loss.

The direct-to-consumer market for stem cell-based interventions in Australia: exploring the experiences of patients

The prevalence of businesses selling autologous stem cell-based interventions to patients in Australia has raised serious concerns about how weaknesses in regulation have enabled the emergence of an industry that engages in aggressive marketing of unproven treatments to patients. Little is known about how patients experience this marketing and their subsequent interactions with practitioners. This paper reports results from 15 semistructured interviews with patients and carers, and also draws upon discussion conducted with patients, carers and family members (22 participants) in a workshop setting. We explore how Australian patients and carers understand and experience these interventions, and how their presumptions about the ethics of medical practice, and the regulatory environment in Australia have conditioned their preparedness to undergo unproven treatments.

The deadly business of an unregulated global stem cell industry

In 2016, the Office of the State Coroner of New South Wales released its report into the death of an Australian woman, Sheila Drysdale, who had died from complications of an autologous stem cell procedure at a Sydney clinic. In this report, we argue that Mrs Drysdale's death was avoidable, and it was the result of a pernicious global problem of an industry exploiting regulatory systems to sell unproven and unjustified interventions with stem cells.

Epidemiological knowledge and discriminatory practice: AIDS and the social relations of biomedicine

This essay examines the relationship between epidemiological knowledge and AIDS-related discrimination. Much of the discrimination literature poses a relationship of mutual exclusion between the everyday practice of discrimination towards People Living With AIDS and biomedical knowledge about AIDS. We argue that if biomedicine is considered as a representational practice rather than a neutral scientific knowledge, numerous points of continuity can be discerned between biomedicine and discriminatory practices. This essay examines three of these points of continuity. They are: the constitution of the borders of 'risk groups', the need to identify the HIV-positive person, and the notion of the direction of infection as it is used to explain the spread of HIV. Comparisons are drawn between accounts of everyday discrimination and these aspects of epidemiological knowledge about HIV.

Women's Sex Talk and Men's Sex Talk: Different Worlds

Communication in heterosexual encounters is often problematic, particularly front the perspective of the woman involved. In examining what renders such communication problematic, this article argues that both hegemonic discourses and particular interpersonal contexts need to be taken into account. Communication and negotiation take place in the intersubjective realm, the space where human beings make sense of their experience. An analysis of memories and accounts provided by groups of men and of women shows how the shared meanings which emerge within such encounters (occasioned meanings) are produced with reference to the dominant discourses. Since these discourses are designed to articulate men's interests, the question of gendered intersubjectivity is particularly salient. Intersubjectivity and negotiation are seen to be related in complex ways. Examples are given of occasions when intersubjectivity is either lacking or incomplete, and it is shown that the male sex drive discourse is one which is then often drawn upon in determining what takes place. This is particularly so for the sexually inexperienced, and thus from a feminist perspective a new discourse of heterosexuality becomes essential.

Stem Cells, Tissue Cultures and the Production of Biovalue

This article examines some of the social and philosophical implications of stem cell technologies. Stem cell technologies promise to transform the way that healthy tissues for transplant are sourced and circulated; from a social economy in which citizens donate whole organs to others, to one in which embryos are a major source of therapeutic tissues. This article considers the transformations in concepts of health, bodily relationships and social indebtedness that such a shift might entail. Using the concept of biovalue, this article describes the ways embryos are biologically engineered to act as tissue sources, and considers the relationship between biovalue, health and capital value. It discusses the effects stem cell technologies may have on concepts of the healthy body, particularly on the temporality of ageing, and on understandings of the human more generally.

The body and the digital archive: the Visible Human Project and the computerization of medicine

This paper addresses itself to some biopolitical issues raised by the computerization of medicine. It is now widely accepted in cultural studies and the sociology of medicine that the computer offers a conceptual model to medicine for the organization of human bodies, and that bodies are increasingly understood as forms of digital archive. However this paper uses one recent development in medical computer imaging, the Visible Human Project, to argue that the computerization of medicine also involves a material reorganization of at least some bodies, a reorganization which reveals a biopolitical hierarchy of more and less valuable bodies within the framework of high-technology medicine.

Biomedicine, tissue transfer and intercorporeality

More and more areas of medicine involve subjects donating tissues to another — blood, organs, bone marrow, sperm, ova and embryos can all be transferred from one person to another. Within the technical frameworks of biomedicine, such fragments are generally treated as detachable things, severed from social identity once they are removed from a particular body. However an abundant anthropological and sociological literature has found that, for donors and patients, human tissues are not impersonal. They retain some of the values of personhood and identity, and their incorporation often has complex effects on embodied identity. This article draws on feminist philosophy of the body to think through the implications of some of these practices. Specifically, it draws on the idea of intercorporeality, wherein the body image is always the effect of embodied social relations. While this approach is highly productive for considering the stakes involved in tissue transfer, it is argued that the concept of body image has been too preoccupied with the register of the visual at the expense of introceptive data and health/illness events. Empirical data around organ transplant and sperm donation are used to demonstrate that the transfer of biological fragments involves a profound kind of intercorporeality, producing identifications and disidentifications between donors and recipients that play out simultaneously at the immunological, psychic and social levels.

'Banking time': egg freezing and the negotiation of future fertility

This paper examines the relatively recent practice of non-medical egg freezing, in which women bank their eggs for later use in conceiving a child. Non-medical egg freezing has only been available for about the last five years, as new vitrification techniques have made the success rates for actual conception more reliable than the earlier method of slow freezing. I draw on interviews with both clinicians and women who have banked their eggs to consider how this novel practice articulates with broader issues about the relationship between sexuality, reproduction and the political economy of household formation. Non-medical egg-freezing provides a technical solution to a number of different problems women face with regard to the elongation of the life course, the extension of education, the cost of household establishment and the iterative nature of relationship formation, thematised by the ubiquity of internet dating among the interviewees. I focus on the ways women used egg freezing to manage and reconcile different forms of time.

Egg donation for stem cell research: ideas of surplus and deficit in Australian IVF patients' and reproductive donors' accounts

We report on a study undertaken with an Australian in vitro fertilisation (IVF) clinic to understand IVF patients' and reproductive donors' perceptions of oocyte (egg) donation for stem cell research. Such perspectives are particularly valuable because IVF patients form a major recruitment group for oocyte donation for research, and because patients and donors have direct experience of the medical procedures involved. Similar studies of oocyte donation have been carried out elsewhere in the world, but to date very little social science research has been published that reports on donation for research, as distinct from donation for reproduction. Our respondents expressed a distinct unwillingness to donate viable oocytes for stem cell research. In our analysis we consider a number of factors that explain this unwillingness. These include the labour of oocyte production, the inscrutability of oocytes (the lack of a test to identify degrees of fertility) and the extent to which the oocytes' fertility sets the parameters for all downstream reproductive possibilities. We draw on the science studies literature on affordances to make sense of the social intractability of oocytes, and compare them with the respondents' much greater willingness to donate frozen embryos for human embryonic stem cells research.

From reproductive work to regenerative labour

The identification and valorization of unacknowledged, feminized forms of economic productivity has been an important task for feminist theory. In this article, we expand and rethink existing definitions of labour, in order to recognize the essential economic role women play in the stem cell and regenerative medicine industries, new fields of biomedical research that are rapidly expanding throughout the world. Women constitute the primary tissue donors in the new stem cell industries, which require high volumes of human embryos, oöcytes, foetal tissue and umbilical cord blood. Such material is generally given for free in the advanced industrial democracies, constituted as a surplus (‘spare’ embryos) or waste (umbilical cord ‘afterbirth’, cadaveric foetuses, poor quality oöcytes) whose generative powers should not be withheld from others. At the same time, among impoverished female populations in developing nations, such biological material is now often procured through frankly transactional relations, where women undertake risky procedures for small fees. In each case, female bodily productivity is mobilized to support bioeconomic research, yet the economic value involved in these relations is largely unacknowledged. In this article, we consider both the gift economy and the transactional economy for reproductive tissues as a form of labour. In order to fully conceptualize the specificities of feminized productivity in the bioeconomy, we distinguish between earlier feminist theories of reproductive labour and the emerging practices generated by stem cell research, which we term regenerative labour. We consider how historical transformations in the regulation of feminized labour and the technical repertoires of stem cell research renegotiate the productivity limits of female reproductive biology, opening it out to novel and profitable forms of surplus value and enrolling women in complex negotiations over their role in bioeconomic activity.

Blood and bioidentity: ideas about self, boundaries and risk among blood donors and people living with Hepatitis C

Clinical medicine and biotechnology increasingly utilise and transform human bodily tissues in novel ways. Today more and more tissues--blood, whole organs, ova, embryos, sperm, skin, bone, heart valves, cellular material, bone marrow and corneas--can be transferred between donors and recipients. Hence more and more people in developed nations have the experience of giving a fragment of their body to another, or receiving such a fragment as part of some kind of therapy. These systems for the circulation of tissues raise the question of what we have termed 'bioidentity'. Bioidentity describes our common-sense understanding of our bodies as 'ours', as both supporting and being included in our social and subjective identities. Within this framework, how are we to understand the status of detachable bodily fragments like blood, ova or organs? As parts of our bodies do they retain a trace of our identity after donation, or are they detachable things? What is our relationship, if any, to the patient who receives our tissues as part of their treatment? This paper investigates the specific case of blood transfusion and donation. It draws upon in depth interviews with 55 people who have specific experience with blood. They either have hepatitis C (are HCV+) acquired by transfusion or intravenous drug use, or have donated blood or received a blood transfusion but are free of hepatitis C (are HCV-). We analyse this material according to the themes--Donated Blood as 'Self', Blood as Alienable, Blood as Communal Substance, and Contaminated Gifts and the Blood of Strangers. We find that, generally speaking the HCV+ and HCV- groups share very similar ideas about blood donation and transfusion. For a minority of both groups, blood was understood as a decisive site of self irrespective of location, but for the remainder donated blood was either ambiguous with regard to identity, a shared substance, or not considered to have any lingering relationship to the self once given. However both groups regarded blood as strongly imbued with 'risk identity'. In particular the HCV+ interviewees regarded their blood as a dangerous personal attribute, one that they must be careful to withhold from circulation, whereas the blood donors felt obliged to donate their blood precisely because they considered it clean and risk free.

The influence of health insurance status on the organisation of patient care in Sydney public hospitals

Utilising intensive semi-structured interviews with health professionals working in public hospitals in Sydney, a comparison was made of the perceived similarities and differences in the medical and administrative management of patients who were covered by Medicare and those who were privately insured. Interviewees argued that there was evidence of preferential access to public hospital care for privately insured patients due to medical misrepresentation of the urgency of their cases. They reported that some medical and administrative practices existed which compromised the choice of admission as a Medicare patient for those with private insurance, and for those without private insurance who were referred to hospital by a specialist. It was suggested also by the interviewees that medical considerations encouraged continuity of specialist care for Medicare patients admitted to hospital when they were known to an attending specialist. Such an allegation places in some doubt the claim made by private insurers that choice of doctor is permitted only under their cover. Interviewees did not report knowledge of any form of compromise in the quality of hospital care on the basis of medical preference for private patients. However, it was reported that private patients may, in some instances, be denied a full range of hospital services due to doctors' attempts to monopolise their treatment.