Should Obese, Smoking and Alcohol Consuming Women Receive Assisted Reproduction Treatment?

January 21, 2010 1:31 PM

The European Society of Human Reproduction and Embryology (ESHRE) has published a position statement on the impact of the life style factors obesity, smoking and alcohol consumption on natural and medically assisted reproduction. Rationing health care is a complicated subject easily politicized. ESHRE has published five recommendations. While smoking and alcohol consumption can have a clearly negative impact on the fetus, so can apparently obesity. Is this part of a slippery slope or needed restraints on medical services?

ESHRE Task Force on Ethics and Law:

1) In view of the risks for the future child, fertility doctors should refuse treatment to women used to more than moderate drinking and who are not willing or able to minimize their alcohol consumption.

2) Treating women with severe or morbid obesity required special justification. The available data suggested that weight loss would incur in a positive reproductive effect, although more data was needed to establish whether assisted reproduction should be made conditional upon prior life-style changes for obese and smoking females.

3) Assisted reproduction should only be conditional upon life style changes, if there was strong evidence that without behavioural modifications there was a risk of serious harm to the child or that the treatment became disproportional in terms of cost-effectiveness or obstetric risks.

4) When making assisted reproduction conditional upon life style modifications, fertility doctors should help patients to achieve the necessary results.

5) More data on obesity, smoking and alcohol consumption as well as other life style factors were necessary to assess reproductive effects. Fertility doctors should continue research in this area.

Obesity
According to the group obesity negatively affected reproductive potential through interference with hormonal and metabolic mechanisms leading to lower ovulation frequency and reduced chances of conception. The risk of gestational diabetes increased from twofold in overweight women to eightfold for morbidly obese women. The infants of obese mothers were at risk of perinatal death, congenital abnormalities such as neural tube defects (80% increase) and cardiovascular anomalies (30% increase).

posted by VikingSword (63 comments total)

I have chosen not to let natural or medically assisted reproduction impact negatively on my food and alcohol consumption.
posted by Horace Rumpole at 1:52 PM on January 21, 2010 [3 favorites]

I am not sure exactly what the question is here. There are already limits on who is given reproductive assistance (for example, a woman with terminal cancer is out)--so limits themselves are not new.

If you are asking "is it ok to limit RA based on whether a woman smokes X amount, drinks X amount, or weighs X amount," then you're not going to get clear answers. There is no right to assisted reproduction, per se, and infertility is not life-threatening. Women of sufficient means will be able to find private RA if state-offered RA is denied to them. You could take this as evidence of fat-discrimination (I don't suppose anyone gets too up in arms about discrimination against smoking/drinking moms these days), but there are much worse examples out there.

This isn't exactly death panels, doesn't seem terribly controversial to me.
posted by emjaybee at 1:54 PM on January 21, 2010

I will be interested to read people's comments on this. As a woman who is infertile and lost my only child to cancer, third party reproduction/assisted reproduction issues are a big deal to me.

When I read the question "Should Obese, Smoking and Alcohol Consuming Women Receive Assisted Reproduction Treatment?" I have to wonder how people would feel about the concept of refusing medical assistance to a woman who could become pregnant in the "normal" way. I take very strong issue with having different reproductive rights just because I suffer from a disease: people with AIDS or cancer or MS or TB or malaria or schizophrenia or otherwise do not have their reproductive rights limited. Neither should I. Fertility clinics already strongly counsel that smoking doubles the number of attempts of (and thus magnifies the already sky-high cost of) IVF treatment, and strongly counsel that patients quit smoking. With the procedure I hope to use, gestational surrogacy, they already subject the woman who will act as the carrier to BMI maximums, mandate non-smoking, etc. (example). There is a strict health review process prior to approval.

I don't pretend to be shocked that the world is so ready to legislate and govern the reproduction of families who are infertile (but can obtain treatment and therefore reproduce). I could go on and on (and have, on my blog) about the number of ways I find that insensitive and inappropriate. But I draw the line at refusing medical treatment for a disease based on obesity. In essence, I think that critics use the fact that the infertile have to obtain "assistance" to reproduce to put in place stringent moral guidelines that would otherwise be impossible, but equally desirable, to reproductively healthy women. In my humble opinion, if we wouldn't refuse a reproductively healthy woman the right to bear a child because she is fat, it is inappropriate to refuse that right to an infertile woman. Furthermore, if current proposals suggest that "lifestyle choices" (including obesity, which is, to be fair, not always a lifestyle choice) are sufficient to restrict what is (in the United States, and yes I recognize this is a European position statement) a "fundamental" right, will we one day restrict the reproductive rights of women who eat too much processed food? Who have high cholesterol? Who will not be emotionally strong and loving parents? Who have disease histories and risk factors? As another example, high maternal age is also linked with a higher rate of birth defects - should we next consider making a Maximum Maternal Age requirement?
posted by bunnycup at 1:55 PM on January 21, 2010 [7 favorites]

Is this part of a slippery slope or needed restraints on medical services?

It's a slippery slope and one with no easy answers. There are also several problems which no one seems to address here.

1) These risk factors are not the primary causes of infertility. Nor are they the primary causes of perinatal complications in babies which are born through infertility treatment.

2) One of side effects of a primary cause of infertility, PolyCystic Ovary Syndrome (now often called PolyCystic Ovary Disease, in an effort by sufferers and the medical community to have its treatment be covered more fully by insurance,) is obesity. There are probably other, similar conditions.

3) Positive results from Assisted Reproduction Technologies (ART) (meaning, a *healthy* baby is born) are very inconsistent, and unpredictable.

4) The greater risk of twins and higher order multiples with ART skew results for required prenatal care. Twins, Triplets and greater typically are born premature, require both pre-and post-natal care. People who have infertility and seek treatment through ART are more likely to have babies which require additional care in the womb and after birth.

5) Reporting systems in the EU, UK and US which would help track results and determine trends are poorly (and in many cases deliberately mis-) managed, so that fertility clinics can artificially inflate their own statistics. SART, the Society for Assisted Reproductive Technology reports clinic success rates to the CDC. A number of studies have shown issues with their reporting methods.

Proposing good patient behavior as a requirement for medical treatment is nothing new. But seeing as this particular medical technology is aimed at helping parents have children, this ruling is bound to be incredibly controversial. Reproduction is a biological imperative for many, and penalizing potential parents is a minefield.
posted by zarq at 2:01 PM on January 21, 2010 [2 favorites]

should we next consider making a Maximum Maternal Age requirement?

Don't they already do this in fertility clinics?
posted by desjardins at 2:13 PM on January 21, 2010

@bunnycup - I see your point, and I'm not necessarily disagreeing with you, but I do think it's worth mentioning that in most countries, there are similar rules about who can and cannot adopt a child. Age, health (including weight), drinking and smoking habits; some countries have rules about all those things. And I've never heard anyone call that discrimination.
posted by fairywench at 2:21 PM on January 21, 2010

Don't they already do this in fertility clinics?

In some in the US, yes. I don't know about the EU or UK.

However, the reason for that policy is not to penalize potential mothers.

The chances that a woman over the age of 35 will be able to conceive a viable embryo which will implant, survive and become a healthy baby, (even with assistance,) decreases every year. Down Syndrome and various other genetic abnormalities become more likely.

Many fertility clinics in the US will warn women who are 35-42 that their chances of success aren't great, but treat them anyway. At that age range, they are more likely to suggest IVF than other, less aggressive techniques, because IVF has a slightly higher success rate. Some fertility clinics in the US will refuse to treat women over a certain age -- typically 42-45.

There is another side to this. Most US fertility clinics produce success rate statistics which are given to SART, who then publishes an annual report and shares them with the CDC. No clinic would admit refusing treatment to those who are unlikely to conceive for the sake of their statistics, but I suspect it happens more frequently than they'd admit.
posted by zarq at 2:29 PM on January 21, 2010

And I've never heard anyone call that discrimination.

Adoption requires the legal termination of another mother and/or father's parental rights, and a state issued court order to create legal parenthood - voluntary or not, a court order is required. With adoption, there is the possibility of dispute over who is the legally authorized parent of the child and as a result, court procedures are involved to resolve them. To put it in an informal way, when the state takes responsibility to authorize (or not) a parent, it informs itself about that parent. Traditional surrogacy - where the woman carrying the child is also the child's genetic mother - typically requires full adoption procedures, again because of the termination of parental rights.

I think there are several pretty clear reasons to draw a distinction. I do, by the way, have a number of issues with adoption procedures, but didn't include them in my earlier comment because they seemed off topic. Not being fighty (at all), but I did want to clarify that I do very much see a practical distinction between ART and adoption that includes but is not limited to issues pertaining to the genetic parentage of the resulting child.

Finally, I do think some people call some of the adoption rules discrimination - for example some US states prohibit single people or those in same sex relationships from adopting. But, I think your point is much more that we accept the idea of regulation in adoption, and I agree that we do (and should).
posted by bunnycup at 2:33 PM on January 21, 2010

By the way, the ages I cite above are not set in stone. Some physicians begin warning their patients that conception may be less likely above the age of 32. Others wait until 38. And the cut-off age varies as well.
posted by zarq at 2:40 PM on January 21, 2010

I don't pretend to be shocked that the world is so ready to legislate and govern the reproduction of families who are infertile (but can obtain treatment and therefore reproduce). I could go on and on (and have, on my blog) about the number of ways I find that insensitive and inappropriate. But I draw the line at refusing medical treatment for a disease based on obesity. In essence, I think that critics use the fact that the infertile have to obtain "assistance" to reproduce to put in place stringent moral guidelines that would otherwise be impossible, but equally desirable, to reproductively healthy women. In my humble opinion, if we wouldn't refuse a reproductively healthy woman the right to bear a child because she is fat, it is inappropriate to refuse that right to an infertile woman. Furthermore, if current proposals suggest that "lifestyle choices" (including obesity, which is, to be fair, not always a lifestyle choice) are sufficient to restrict what is (in the United States, and yes I recognize this is a European position statement) a "fundamental" right, will we one day restrict the reproductive rights of women who eat too much processed food? Who have high cholesterol? Who will not be emotionally strong and loving parents? Who have disease histories and risk factors? As another example, high maternal age is also linked with a higher rate of birth defects - should we next consider making a Maximum Maternal Age requirement?

I read this, and I think I agree with you. There's definitely a good case not to make moral decisions for a woman which she is capable of making herself. But there's the minor factor in the concerns around alcohol/smoking/obesity causing infertility that make "lifestyle" changes the primary treatment for the disease, and it would be morally wrong for doctors not to give them priority in applicable cases. Otherwise, I think maybe the concerns of the ESHRE are best understandable from the moral position of doctors and the state-as-healthcare-provider. Rather than seeing this as a moral imposition upon women made possible by the need for medical intervention, we could view it as a moral problem for those who are called to make the very same moral choices as the prospective mother. Both the doctor and the state might object on the grounds that they are being called to potentially harm a future person*, or to use health resources inefficiently. That still runs into the same iffy place where the woman's ability to decide is overridden, but doesn't allow extension of this position into pregnancies not assisted.

I still agree with you in general, however.

*I wonder how similar this might be to contraception provision, including abortion, which appear on the surface to have shared characteristics. But unlike in abortion, where the fetus has no moral claim to health above that of the woman as it does not and will not have human existence; do we here have to take into account the rights of the "unborn child" - not as a fetus, but as a prospective human? I really don't know.
posted by Sova at 3:21 PM on January 21, 2010

One possible issue with obesity limits is the time factor. I'm currently, generously, about a hundred pounds overweight. At the fastest rate I could safely lose that weight, I would have to put off any fertility treatments for a minimum of a year, more likely two. I'm 34, which is getting perilously close to the 35 year mark. What if a woman was 38? Are her chances as a fat 38 year old really worse than they are as a slim 40 year old?

fortunately I have no sign of needing any reproductive assistance (I have a crapping-out thyroid which is probably the cause of my recurrent pregnancy loss) but the time factor is something to take into account.
posted by KathrynT at 3:38 PM on January 21, 2010

In my humble opinion, if we wouldn't refuse a reproductively healthy woman the right to bear a child because she is fat, it is inappropriate to refuse that right to an infertile woman.

You should really think this through. Person X has the "right" to do something that and that right is to be paid for by others.

I don't actually disagree with you, since I think that dysfunction in general should be treated, but it's worth asking how far this extends.

There are finite funds and all "cover/don't cover/restrict" choices are in fact prioritizations.

Rationing health care is inevitable and required. For example, end of life care costs need to be brought under control and they will be subject to exactly the sort of claim to resources you are making. Should we prioritize, say, prevention of some disease at some cost Y over treating (possibly) self-induced infertility? This should not be done emotionally ("denied the right"), it should be done quantitatively (the greatest good).
posted by rr at 5:31 PM on January 21, 2010 [3 favorites]

Question: anyone know the broader ethical guidelines on refusing non-lifesaving treatment to patients based on lifestyle choices?
posted by foxy_hedgehog at 5:47 PM on January 21, 2010

You should really think this through. Person X has the "right" to do something that and that right is to be paid for by others.

In the United States (where I live, though as said I recognize that this is a European ethics opinion), ART is not paid for by others. It is not even paid for by private insurance in most cases - especially where "advanced" ART is used. As I have seen in my activity/commentary/participation in the infertility community, with particular respect to IVF, it is paid for out of pocket, at a cost to the individual of tens of thousands of dollars.

I can't determine your location and I recognize that you may be in a country where this (or any other health care for that matter) is provided for you. I would recognize an argument that these services should not be insured, and in fact, on my blog, I recently wrote a lengthy article explaining my acceptance of theory under which they are not insured. But to step outside and look at the philosophical, and ethical questions presented in this FPP (that is, whether certain women should be refused treatment for infertility even though biologically/physically eligible) - I have very much thought this through.

I have done little but think this through, since April 24, 2008 when I had an unplanned, emergency hysterectomy necessitated by massive bleeding a couple of hours after childbirth. I thought this through when I wrote about the issue over the past several months. I thought it through when I began the process of a surrogate pregnancy, chose a fertility clinic, and obtained the expected cash costs. I thought this through when I began to accept that I very well might not be able to have a second child, because I may not be able to afford those cash costs. I thought this through when I considered ways to finance the ability to reproduce, started desperately collecting cash and asking friends and family for help. And I thought it through when other women around me became pregnant with ease or accidentally. I continue to think this through, after a layoff in my immediate family has once again made the costs of ART so far out of reach as to be nearly impossible. But, as difficult as it may be and as improbable that I will ever be able to afford it, at least I am allowed all rights of reproduction permitted by my biology.

Think that through, okay?
posted by bunnycup at 5:56 PM on January 21, 2010 [1 favorite]

Sadly many infertile or subfertile women suffer from PCOS-and part of that condition is weight gain plus extreme difficulty in losing weight.

What a heartbreaking catch-22 for a woman who just wants to be a mother...
posted by St. Alia of the Bunnies at 6:04 PM on January 21, 2010 [1 favorite]

(Just to be clear: my last comment above is a very emotional appeal. Having children, and how and when, is an emotional and personal decision. Both logically and emotionally, I feel it is inappropriate for any state to govern when and how any person may reproduce, whether assisted or otherwise. Those who can reproduce in the "normal way" would never accept such governance over their reproduction, and despite the occasional popularity of suggestions of stricter rules over ART - usually based on a mistaken understanding of the prevalence of abuses such as the Suleman case - neither will I. This is a deeply personal, upsetting situation that intimately affects my life on a daily basis. Hence, the very emotional appeal. I will now have to step out of this conversation, because I have crossed the line into being too strident and emotional.)
posted by bunnycup at 6:11 PM on January 21, 2010 [1 favorite]

bunnycup, I don't think you were being 'strident and emotional' and I would hate to lose you from this discussion as you obviously have thought about these issues a lot. I disagree with your position and I will try to respectfully show where I disagree.

You appear to be arguing from a reproductive rights position and arguing against governments setting 'moral conditions' on assisted reproductive therapy.

My personal position is that ART should not be paid for by the government. I don't believe in curtailing a female's reproductive rights, but by these rights I understand her natural ability to have children and not her 'right' to assisted reproductive therapy. I don't actually know your position on this re government assistance as you appear to be in the USA where it is my understanding you don't get any. If you don't have government providing ART assistance then presumably they won't be setting 'moral conditions' on the use of ART.

From a small amount of research on the ESHRE who I haven't heard of before, it appears to be a professional association for people who work in this area in Europe. It is entirely appropriate for such professionals to develop and agree on a code of conduct for the work they do and the work they will not do. That is what is being published here or at least a move in that direction. You may not agree with what they are saying, in which case you are free to go to someone who is not bound by this code of conduct, and while you can argue against their code of conduct you can not deny them their own self-governance.

If you go to someone for assistance then it in entirely their right to define the limits of assistance they will give.
posted by Pranksome Quaine at 6:53 PM on January 21, 2010 [2 favorites]

Hugs ((bunnycup)). I think it's really difficult for people who aren't going through infertility issues to understand. I recently came to the decision to stop actively pursuing pregnancy. We could not afford anything more than a few rounds of IUI. It is very painful to look at the crib in my garage and have the realization, "there's only going to be one child, no more than that." I am grateful for my one child; I know other infertile couples who don't even have that.
posted by echolalia67 at 7:31 PM on January 21, 2010

In the United States (where I live, though as said I recognize that this is a European ethics opinion), ART is not paid for by others

Yes, and in the US this isn't covered by the insurance or the government.

In the case of ESHRE, however, which is the topic, the recommendations are being made in the context of a system with publicly provided healthcare.
posted by rr at 7:38 PM on January 21, 2010

Yes, and in the US this isn't covered by the insurance or the government.

I'd like to correct this statement. It isn't true. rr, I realize you're trying to restrict the conversation to publicly-provided healthcare, but I think it's important that no one reading this thread come away with false information.

The US federal government does not cover ART.

There are several insurance plans here in the US which cover some or all IUI, IVF, GIFT and/or ZIFT procedures. They may cover medication, diagnostics and the procedures themselves or some combination of the two. Most of the larger companies offer some sort of infertility rider, which can be tacked onto an existing policy to gain coverage, which may take the form of standard insurance, a refund plan or medical loans.

Fertility clinics work very hard with couples to make sure they have access to their insurance coverage, when possible. It's in their best interests.

However, there are several caveats.

1) a couple must meet certain criteria to qualify. They must be under a certain cut-off age, which varies from policy to policy. (It's usually 40.) They typically must show a medical diagnosis of some form of potential infertility or prexisting condition which may lead to reproductive problems. And often an insurance company will demand that they be policy holders for 6 months to a year before fertility coverage begins.

2) Insurance companies will often push people to go the IUI route first, rather than IVF. IUI is far less expensive, and often requires less medication. However, it is also often less successful than IVF. Often they will demand that IVF wait until a certain number of IUI cycles have been tried without success. This can cause serious problems for couples with a history of miscarriage. Also, IUI carries a greater risk of higher order multiples than IVF.

There are some states that actually make infertility coverage mandatory at no additional cost if a person works for a company that has over 50 employees covered.


In addition, there are several programs run by privately held fertility clinics and at least one or two organizations across the US, wherein at least one free IVF cycle would be donated each month to families in need who applied. (Disclaimer: I used to work with a chain of clinics that did this, as well as a non-profit that ran a similar program.)
posted by zarq at 8:08 PM on January 21, 2010

However (and this is a big however,) the existence of such insurance policies and riders does not mean that they are affordable.

If not covered, then IVF is extremely expensive here. It starts at $8,000, and usually costs at least $12,000-$16,000. Drugs may run to at least $1000 per month or more. It may cost a couple anywhere from $15,000 - $20,000 for a single IVF cycle. And even the very best odds place the chances of conception through IVF at about 20%.
posted by zarq at 8:23 PM on January 21, 2010

Thanks, zarq, for the correction.
posted by rr at 8:31 PM on January 21, 2010

In the case of ESHRE, however, which is the topic, the recommendations are being made in the context of a system with publicly provided healthcare.

rr, I think I made pretty clear in every single comment I made here that I am speaking to the philosophical and ethical points, and I don't think your approach that these are not part of the topic of discussion is supported either by the post itself or the discussion as it has evolved. There are various proposals to regulate ART in different ways in different US states right now, and drawing from the approach and opinions of other worldwide bodies, comparing the ethics involved, etc. is useful and on-topic. Particularly insofar as traveling abroad for ART/3PR procedures is common, with traffic moving in all directions (to the Ukraine, to India, from Europe or Australia to the United States, etc.)

Further, to the extent of the press release in the first link, I would love someone to clarify. It is a "reproductive science and medicine" journal that, by the language I read in the article, does not contain words to the effect of refusing government insurance coverage for ART in these situations, but instead states that "Assisted reproduction should only be conditional upon life style changes". As I read that (but again, would be interested in further details), on its face it makes the procedure (not simply government payment for such) contingent on lifestyle requirements. Accordingly, it's not clear to me at all that the assumption that this pertains only to payment for same is valid.

But even assuming this medical/scientific journal is addressing government policy/insurance coverage (which it doesn't appear to me to be doing) putting in context against publicly funded healthcare in other countries, are those who carry heritable diseases (and whose children have a greater-than-average high likelihood of sickness or serious, costly illness) discouraged from reproducing? If ART is to be denied to smokers or obese women (but not men?) on these grounds, should it be denied to carriers of cystic fibrosis genes? Breast cancer genes? INI1 mutations? It seems to me the same logic could apply. It's a rhetorical question of course (and not meant to fully equate denial of reproductive assistance to eugenics), asked to point out how much more important the ethical questions are than the blinders approach of "government pays, government decides whether to cover". And that said, separate from the pre-conception cost of the procedures, if the intent is to protect the quality of life of the future child and limit government costs, these are long term questions and the health costs over a sick child's life dwarf the ART costs. Shouldn't the prohibitions then apply equally to fertile couples? Why should the rest of the population have to pay for their sick children? Again, completely rhetorical and not intended to be taken as a dead serious statement - I don't believe the restrictions should apply to any family.

On preview: Sorry I use parenthetical references so much, it must make my thoughts really difficult to parse.
posted by bunnycup at 8:38 PM on January 21, 2010 [1 favorite]

As a sort of side-note to what bunnycup has so eloquently explained....

This is an intensely personal issue for many couples. Reproduction is (as I stated above,) a biological imperative. It is also a cultural one. Infertility creates fundamental psychological issues in many couples that they may find difficult to resolve. Men and women with infertility may feel that they are unable to fulfill one of their gender-specific roles. (i.e., the perception that one is not a "real" man or women unless they produce a child.) They may feel that they have let their spouse down, because they are unable to provide them with children. Plus, they are surrounded by cultural cues that both support parents and worship cute babies.

Because of this, infertility contributes to many divorces. It's not unheard of for an infertile spouse to try to convince their partner to pursue a divorce and find someone with whom they can create a family.

So, into this social and emotional environment step a couple who is trying to conceive. They must first go through what many of them view as humiliating, invasive diagnostic procedures and embarrassing explanations and conversations with physicians about subjects that they would never willingly discuss with anyone. But they must determine what, if anything is affecting their ability to conceive, so they endure. Once that determination is made, they then have to review their options.

Here in the US, this will also entail a frank assessment of whether or not they will be able to afford to conceive children. What the rest of humanity takes for granted may be denied them if they can't raise enough money, or borrow it from a bank or family and friends. The unfairness of this proves frustrating, and rage-inducing for many people. This will be exacerbated if the procedure doesn't work, which is likely. 5 cycles of IVF can cost more than $100K here. (Median annual household income is half that, minus another third for taxes. So $100K might be three years salary -- before living expenses!)

And they may have to deal with insurance. Which is usually a total nightmare because it involves approval for time sensitive procedures, expensive medications and once again, discussions of sensitive topics with total strangers. You need help getting an erection, and insurance will help you. Try and have a kid, and insurance becomes an obstacle course deliberately created because the companies that cover ART see it as an unpredictable loss-leader, thanks to the high failure rate.

Do they tell their friends? Probably not. Most people consider the topic taboo. Do they tell their families? Again, probably not. There is a stigma associated with infertility, and it is worse in certain cultures than others. Many middle eastern couples or ultra-religious couples come to the US to be diagnosed and treated, and to take their chances with ART. They suffer it all in silence.

Consider all of these factors. Then consider how each couple might react to being told that they don't qualify to have a child, because they meet certain criteria -- one of which, by the way, is a symptom of one of the most common forms of infertility! It's been estimated that 5-10% of women of reproductive age have PCOS to some degree.

If someone tried to enact similar restrictions here, it would likely provoke a nasty backlash. Consider: the entire pro-choice movement has been based on the idea that women should be allowed control over their own bodies so that they can make a choice of whether or not to have a baby (or babies, as the case may be). The moment any organization or the US government begins to tell women that it knows better than they do how they should have children... well, I certainly wouldn't want to be in the line of fire on that issue.
posted by zarq at 9:27 PM on January 21, 2010 [2 favorites]

rr, you're welcome.
posted by zarq at 9:43 PM on January 21, 2010

You have a right to free speech, i.e. the government does not curtail your speech. You don't have a right to the government building you a printing press.

You have a right to reproduction, i.e. the government does not curtail your reproduction*. You don't have a right to the government assisting you for fertility problems.

As I see it rights are restrictions on the government curtailing your freedom. They are not entitlements to government assistance.

Of course, societies and governments may decide to give assistance, but that is then a benefit not a right.

I argue against the government benefiting people through providing ART. The reasons I argue that way is because 1) I find a lot of the technology distasteful (too intrusive), 2) I know it can be an emotional roller-coaster for the parents, 3) it is expensive and 4) it is too much of a focus on fixing problems and not on healthy lifestyles. But that of course is just my single personal opinion.

I still uphold the right of people to seek out ART. I would also support private insurance covering it.

In a state without government provided ART it is entirely acceptable for the private providers to adopt a code of conduct. This is very simple. But even inside a state where ART is at least partially provided by government it is still completely acceptable for the professionals providing the service to form voluntary associations with a code of conduct and even lobby for this code of conduct. In fact I think this is very healthy. We accept this for engineers, accountants, teachers and standard doctors. Why not fertility professionals?

You may argue with the case this particular association is making but surely you are not arguing with their right to form this association and debate and lobby on fertility issues?

_{* Although it does in the case of incest.}
posted by Pranksome Quaine at 9:52 PM on January 21, 2010

4) it is too much of a focus on fixing problems and not on healthy lifestyles.

Pranksome Quaine, what are the primary causes of infertility, and what percentage of them can be corrected by the promotion of a healthy lifestyle?

If you don't know the answer to this, then forgive me, but you're not qualified to make a value judgment about whether current infertility treatment focuses too much "on fixing problems and not on healthy lifestyles."
posted by zarq at 9:58 PM on January 21, 2010 [5 favorites]

I thought someone might try to call me out on that. Obviously some infertility is caused by genetic disorders, such as the case with my uncle who had Klinefelter's syndrome. But obviously as well some is caused by lifestyles. I don't care what the exact percentage split is because I am quite confident that lifestyle factors are not an insignificant contributor. Do you want to provide figures to contradict me? From what is written above the ESHRE obviously consider them a significant contributor and are trying to signal their lesser enthusiasm for helping in these cases.

And now I'll call you out on something you wrote that caused me to raise an eyebrow:

Here in the US, this will also entail a frank assessment of whether or not they will be able to afford to conceive children. What the rest of humanity takes for granted may be denied them if they can't raise enough money, or borrow it from a bank or family and friends.

It's not my experience that the rest of the world blithely take for granted their ability to afford a child.
posted by Pranksome Quaine at 10:18 PM on January 21, 2010

The answer to your question is that the risk factors referenced by the ESHRE affect approximately 20-25% of infertility cases in men, and approximately 5-8% in women. This is my understanding, from having worked with a number of reproductive endocrinologists. These numbers are approximate for several reasons, but primarily because they vary from culture to culture. Obesity is more of an issue in the US than many other countries, for example.

What this means is that the majority of infertility cases are due to genetic, hormonal, immune or physical problems, rather than lifestyle issues alone. Women are FAR less likely than men to have infertility issues that are caused by their lifestyle. For women in the US by the way, the primary risk factor is being either under- and over-weight. I've already addressed the latter, in a previous comment.

Courtesy of the Mayo clinic:

40-50% of infertility cases are solely a problem with the female partner.

The most common causes of female infertility include fallopian tube damage or blockage, endometriosis, ovulation disorders, elevated prolactin, polycystic ovary syndrome (PCOS), early menopause, benign uterine fibroids and pelvic adhesions.

None of these can be corrected through non-medical intervention, i.e. lifestyle changes.

Other causes in women: Medications, Thyroid problems, caffeine intake, Cancer and its treatment, Other medical conditions, including medical conditions associated with delayed puberty or amenorrhea, such as Cushing's disease, sickle cell disease, kidney disease and diabetes. Age.

Only one of these can be corrected through non-medical intervention: Caffeine intake, and studies actually conflict as to whether or not it is a problem.

On to the men:

In about 20 percent of cases, infertility is due to a cause involving only the male partner.

In about 30 to 40 percent of cases, infertility is due to causes involving both the male and female.

And I'll bold this as well so it's clear: Male infertility is more likely to be affected by environmental and lifestyle changes.

What are the primary causes of infertility in men?

The most common causes of male infertility include abnormal sperm production or function, impaired delivery of sperm, general health and lifestyle issues, and overexposure to certain environmental elements.

Most cases of male infertility are due to sperm problems: Impaired shape and movement of sperm, Low sperm concentration, Varicocele, Undescended testicle, Testosterone deficiency (male hypogonadism), Genetic defects, Infections and STD's, Inflammation of the prostate (prostatitis), urethra or epididymis.

Okay. Some of these: STD's and infections, decreased sperm count and motility and (rarely) testosterone deficiency, can certainly be caused by lifestyle.

Also see: General health and lifestyle: including Emotional stress, Malnutrition, Obesity, Cancer and its treatment, Alcohol and drugs, Other medical conditions, including diabetes, thyroid disease, Cushing's syndrome, or anemia may be associated with infertility.

Environmental exposure: Pesticides and other chemicals, Overheating the testicles, Substance abuse, Tobacco smoking.

-----------------------------------------------------------------------------------

You said: I don't care what the exact percentage split is because I am quite confident that lifestyle factors are not an insignificant contributor.

I agree that the risk factors are not insignificant. You said: "4) it is too much of a focus on fixing problems and not on healthy lifestyles."

OK. So, I want you to support this statement.

From what is written above the ESHRE obviously consider them a significant contributor and are trying to signal their lesser enthusiasm for helping in these cases.

This is not proof that those risk factors deserve focus at the expense of denying treatment to anyone. We have already established that the risk factors they list are not the primary causes of infertility. We have also established that one of their suggested criteria, obesity, is a symptom of one of the leading causes of infertility.

One could therefore easily claim that they are placing blame on and penalizing the infertile, rather than focusing on the far more prevalent and severe causes that matter.
posted by zarq at 11:01 PM on January 21, 2010 [6 favorites]

It's not my experience that the rest of the world blithely take for granted their ability to afford a child.

You quoted me, then left out the word "conceive" from your response.

I said: "Here in the US, this will also entail a frank assessment of whether or not they will be able to afford to conceive children. What the rest of humanity takes for granted may be denied them if they can't raise enough money, or borrow it from a bank or family and friends."

For fertile couples, it costs nothing to conceive children.

Being able to afford to provide for them once they're born is beyond the scope of my comment.


Or am I misunderstanding what you are trying to say?
posted by zarq at 11:06 PM on January 21, 2010

One thing I left out of the insurance run-down, above:

I know that many (perhaps all?) insurance policies / infertility riders do curtail the number of cycles of each procedure you can have in.a given year, if they cover ART.

So you may get 6 IUI cycles and 2 IVF cycles per year at full or limited coverage.

Something is better than nothing, of course. But fertility treatment is time sensitive for women as they age. If the only way they can afford treatment is insurance, (and they're lucky enough to have coverage!) then such limitations may delay progress unnecessarily.

I'm sorry to go on and on about insurance, especially considering that it's sort of a sidebar from the FPP topic. I'm truly not trying to derail the thread... just trying to give a little perspective on the challenges involved.
posted by zarq at 5:29 AM on January 22, 2010

zarq, I appreciate your going on and on about insurance, and also about the causes of infertility to zap some of the bad assumptions stated upthread out of the water. I think people have a concept that infertile couples don't "need" or "deserve" ART, and that approach is as strong as I've seen it anywhere in some of the comments here. Although the ESHRE doesn't seem to address the issue of payment so much as availability of services, there seems to be an absolute willingness to deny the services alltogether.

Pranksome Quaine said: I argue against the government benefiting people through providing ART. The reasons I argue that way is because 1) I find a lot of the technology distasteful (too intrusive), 2) I know it can be an emotional roller-coaster for the parents, 3) it is expensive and 4) it is too much of a focus on fixing problems and not on healthy lifestyles. But that of course is just my single personal opinion..

I also think it's interesting how much, as compared to other areas of life, the public at large seems to think it has a right to judge reproductive medical treatment. I can't have medical treatment because you think it's too intrusive? Or will be an emotional rollercoaster for me? Talk about paternalism. It's quite frankly none of your business.

Just to be clear, I continue to think the issue here is not payment for services, but availability of services. FTA:

The group made five recommendations.

1) In view of the risks for the future child, fertility doctors should refuse treatment to women used to more than moderate drinking and who are not willing or able to minimize their alcohol consumption.
...
3) Assisted reproduction should only be conditional upon life style changes, if there was strong evidence that without behavioural modifications there was a risk of serious harm to the child or that the treatment became disproportional in terms of cost-effectiveness or obstetric risks.
...
5) ...The respect for patient autonomy needed to be balanced with the moral weight of the interests of society and the future child.

I think the idea that one can respect the moral interests of the future child by disallowing people to conceive that same child, is unusual. And again, evidence that these recommendations are about the refusal of treatment alltogether, and not payment for it. It reminds me of the Roman Catholic Church's convoluted reasoning against IVF, that it deprives the child of it's "right" to be the product of physical copulation from married people, and that the deprivation will permanently injure the child's personality, family unity, etc.

As I said above, of the moral rights and future interests of the resulting child (and society's costs in providing the child's medical treatment) are so very persuasive, then the prohibitions proposed by this group should apply to all parents.
posted by bunnycup at 6:40 AM on January 22, 2010 [2 favorites]

Neither bunnycup nor zarq have addressed the main point I made very early - that a professional body has the right to set a code of conduct or boundaries in which they will work. This is the main focus of the document that forms the basis of this thread. You appear to resent that they are doing this.

You've brought in much other detail that is extraneous to this point but is, I grant, of some relevance to the issue of ART. However I don't believe either of you have clearly stated your position on the fundamental question that we need to settle which is who pays? I've stated my position - that I don't believe in the government paying for high-tech treatments for either genetic or lifestlye caused infertility. That's not paternalism - it's my personal position on whether I am happy for my government to provide benefits in this area. I've told you why I don't believe it's a right and I don't believe you've made a good counter-argument to that.

I'm certainly not stopping anyone from getting the treatments either by direct payment or by private insurance cover. But if you want to do it with government money you're the ones who have to make a case to the community. Your case does not convince me and frankly it comes across very clearly as simply a sense of entitlement - Other people can have children, I should be able to too. - Other people only start having to pay for their children after they're born, why should we have to pay for them before conception?

I understand that being infertile can be a huge trauma. But it's not one that society has inflicted on you - it's either by nature or by self-nurture so to speak. It is a request, a plea, that you are making to your society to support your treatments. If society doesn't believe in providing that benefit then you have to respect that.

I'm sorry bunnycup but you took the gloves off when you accused me of paternalism and basically told me to butt out. I welcomed your input, but I have to say that you and zarq are providing a lot of extraneous detail that skirts around the main points as I see them and have clarified in this comment.

Obviously the ESHRE doesn't agree with my blanket refusal of service. Indeed they are on the other side of the fence providing these services. I respect that and I respect their position. I also appreciate that they are setting some ethical guidelines for their members to follow. I welcome the debate on this issue and I respect that there will be a range of positions. I would also accept the broad consensus of any community I live in on ART. But I won't accept being told that because I'm not infertile I'm a cold heartless bastard for expressing how I feel about the practices involved in ART and making my position clear on whether I'm wanting my government to fund it.

I also think that zarq's attempt to link ART to the pro-choice movement and bunnycup's attempt to tar everyone who questions the provision of ART with the brush of the Catholic Church are both preposterous. I personally am completely pro-choice and am definitely not a member of the Church of Rome, nor any Christian church.
posted by Pranksome Quaine at 7:51 AM on January 22, 2010 [1 favorite]

I also think that zarq's attempt to link ART to the pro-choice movement and bunnycup's attempt to tar everyone who questions the provision of ART with the brush of the Catholic Church are both preposterous.

In the United States (where I, and I believe zarq) live, pro-choice and ART are intimately tied, because both are founded on a "right to reproduce". In the United States, whether or not to have a child is a decision shielded by constitutional privacy (Griswold v CT, Roe v Wade, etc.) and subject to government intervention only in very limited ways. Hence, they are very, very tied in this way. It is further worth examining the relationship of reproductive choice (you know that means the choice whether or not to reproduce right? and that pursuing ART is a decision to reproduce?) and ART is tied in the US because of laws here that make abortion available but typically not paid for by insurance in most cases. The whys and wherefores of that are interesting to compare with the whys and wherefores of coverage to create rather than terminate a pregnancy. If you don't understand these issues, it really is okay to ask someone to explain them to you or to go do a little Googling, at least before raising the "I'm being attacked" cry.

It is not preposterous to say that two groups (in this case, ESHRE and the RC church) are similar when they use almost the very same words - worrying about the future moral rights of a child that their guidelines are depriving of the right to be born at all. I'm not sure where you read this as a personal attack against you, but I don't recall you even exhibiting that opinion.

In addition to the questions of carriers of genetic disorders and related other cases (which remain unanswered), what about cancer treatment for those whose lifestyle caused lung cancer (after all, as you point out, society didn't inflict that trauma on those patients)? Should that be provided? These proposed ART restrictions are addressed at women only - should mens' health and lifestyle choices be taken into account as well? Good statements have been written above by zarq showing that lifestyle changes are actually more important for men than women.

But I won't accept being told that because I'm not infertile I'm a cold heartless bastard for expressing how I feel about the practices involved in ART and making my position clear on whether I'm wanting my government to fund it.

You are leaving a really disingenuous impression by misquoting zarq (and not acknowledging it) and responding to broad personal attacks against you that were never made. Please don't do that (or MeMail if you really want to continue), I'd really like to be able to continue to have this discussion because it's very interesting and important to me, as I explained above.
posted by bunnycup at 8:35 AM on January 22, 2010 [1 favorite]

Neither bunnycup nor zarq have addressed the main point I made very early - that a professional body has the right to set a code of conduct or boundaries in which they will work.

Perhaps I'm not being clear.

The problem is not that they don't have the right to do this. They do.

Here are the problems I have noted with what they are doing:

* ESHRE is focusing on risk factors which are a minor issue in female infertility. Female infertility is overwhelmingly not caused by the lifestyle factors they cite. Nor are these risk factors the primary causes of perinatal or postnatal complications in babies which are born through infertility treatment.

* They are ignoring at least one serious flaw in their reasoning. Obesity in infertile women can be a symptom of one of the leading causes of infertility: PCOS, which is a hormonal disorder of the endocrine system that can cause (among other things,) weight gain and infertility. It affects between 5-10% of all women and PCOS is the most common hormonal disorder affecting women of reproductive age. To ignore this and then restrict infertile women from fertility treatment for being obese is just mind-boggling.

* Men are far more likely to be affected by environmental and lifestyle factors than women. Yet they are not mentioned in this document.

* Twins and higher order multiples are typically are born premature and require pre- and post-natal care whether or not they were conceived through ART. People who have infertility and seek treatment through ART are more likely to have such babies, which require additional care in the womb and after birth. The risk factor there is the birth of higher-order multiples, not a lifestyle behavior.

Given these facts, it seems apparent women are being unduly penalized here.

This is the main focus of the document that forms the basis of this thread.

Yes, it is. I've addressed that focus several times now.

You appear to resent that they are doing this.

I feel it's unfair to women, which frustrates me.

You've brought in much other detail that is extraneous to this point but is, I grant, of some relevance to the issue of ART.

And I really, truly and sincerely am not trying to derail this thread. I just felt it was important to add.

However I don't believe either of you have clearly stated your position on the fundamental question that we need to settle which is who pays? I've stated my position - that I don't believe in the government paying for high-tech treatments for either genetic or lifestlye caused infertility. That's not paternalism - it's my personal position on whether I am happy for my government to provide benefits in this area. I've told you why I don't believe it's a right and I don't believe you've made a good counter-argument to that.

I can't speak for bunnycup or her motivations. I agree with most of her positions, although I don't believe that the public should be under obligation to pay for anyone's non-life-threatening medical treatment if they don't want to. So no, I don't think a government should be obligated to pay for these services. If the public wishes them to do so, then that's fine with me. More on this in a moment....

However, the creation of an arbitrary group who will be refused services based on flawed reasoning is wrong. And ESHRE'S reasoning is flawed.

I understand that being infertile can be a huge trauma. But it's not one that society has inflicted on you - it's either by nature or by self-nurture so to speak. It is a request, a plea, that you are making to your society to support your treatments. If society doesn't believe in providing that benefit then you have to respect that.

What other non-life-threatening medical treatment does EHIC typically pay for? Corneal transplants? Knee surgeries? Non-urgent heart valve replacements? Varicose vein surgery? Hip resurfacing or replacement? Vision? Dental care?

The answer is, some are covered completely nearly all are covered partially, and it varies from EU state to EU state.

Are any of these or other nonlife-threatening conditions which are also afflicted "by nature or by self-nuture" restricted by the medical community due to a patient's lifestyle choices? Say, do they deny vision care to folks with glaucoma, for example?

If not, then why are infertile women being singled out here? If not, how is that not paternalism on the part of the ESHRE?

I also think that zarq's attempt to link ART to the pro-choice movement and bunnycup's attempt to tar everyone who questions the provision of ART with the brush of the Catholic Church are both preposterous. I personally am completely pro-choice and am definitely not a member of the Church of Rome, nor any Christian church.

The pro-choice thing was an example which I specifically and clearly applied to the US only, and it's actually relevant here in that the ESHRE guidelines restrict reproductive choice. As do the pro-life movement and the Catholic Church, in the other direction.

I certainly didn't intend it as a criticism of you personally.
posted by zarq at 9:02 AM on January 22, 2010 [2 favorites]

zarq, I appreciate your going on and on about insurance, and also about the causes of infertility to zap some of the bad assumptions stated upthread out of the water.

Thanks. I'm just mindful that by flooding the thread with info about insurance in a country where the ESHRE guidelines don't apply that I could be causing problems. I didn't want to confuse people who might be reading or worse, steer the thread...

I think people have a concept that infertile couples don't "need" or "deserve" ART, and that approach is as strong as I've seen it anywhere in some of the comments here.

It's a common perception. Not just on MeFi.

I used to conduct pre-interviews of fertility patients prior to their speaking with the media about their experiences. One of the questions I used to have to ask them was "Why did you choose this route? It's expensive, it's hard on you physically and emotionally, and it's unreliable. You don't know if this is going to work. Why not just adopt?" Because the media did ask those questions, and they needed to be able to answer. Frequently people characterized their own decision to have a child with assistance as: "I know it's selfish of me, but...."

I wasn't allowed to coach them. (The idea behind a pre-interview is to assess whether a patient is articulate and can handle difficult questions without being inappropriate, not if their answers are acceptable to your client.) But I often found it stressful and frustrating to not be able to try and make them feel more comfortable with what they were doing.

Although the ESHRE doesn't seem to address the issue of payment so much as availability of services, there seems to be an absolute willingness to deny the services all together.

Hrm. We know that insurance companies don't like covering ART because doctors can't predict results, and success in ART raises the chances of twins, triplets or greater -- which results in big hospital bills. I haven't seen an insurance infertility rider in a couple of years. I'd have to go back and check my files, but I wonder if insurance companies ever cite behavior as reason to deny infertility coverage....
posted by zarq at 9:47 AM on January 22, 2010

I haven't seen an insurance infertility rider in a couple of years. I'd have to go back and check my files, but I wonder if insurance companies ever cite behavior as reason to deny infertility coverage....

My insurer covers infertility if certain conditions are met (Oxford/UnitedHealth in Connecticut, which state mandates infertility coverage for men and women). I don't have the rider in front of me at the moment, but I read it very carefully in August 2009. Here are some comments on how it operates:

-Infertility coverage denied when infertility is the result of voluntary sterilization (i.e. tubal ligation, vasectomy) procedures. I don't recall seeing any other "lifestyle" type limitations.
-There are bars to accessing the services, in terms of a specific definition of infertility. I believe it requires 6 months of trying to conceive naturally for certain problems and 12 months for others.
-I believe services must be provided at an ASRM-member clinic, to be eligible. ASRM has certain ethical guidelines it requires of member clinics. Per ASRM "They are not intended to be a protocol to be applied in all situations, and cannot substitute for the individual judgment of the treating physicians based on their knowledge of their patients and specific circumstances. The recommendations in these guidelines may not be the most appropriate approach for all patients." ASRM seems to me to have a very different, more individual patient-based approach than ESHRE.
-Services are graded, for example you can't jump straight to IVF. Less complicated procedures (hormonal treatments, AI) must be exhausted before more complicated and more costly procedures can be reimbursed.
-With respect to IVF, only 2 attempts are covered and they will only be covered for, I believe, the implantation of 2 or less embryos. I recall there may be an exception for implanting more embryos if medically necessary, but I don't think so. I presume this is done as an ethical and future cost controlling measure, i.e. to minimize the risk of multiples.
-No coverage is provided for the cryopreservation, storage or thawing of embryos.
-I do believe there is a maximum age after which the coverage is no longer available.

Thanks. I'm just mindful that by flooding the thread with info about insurance in a country where the ESHRE guidelines don't apply that I could be causing problems. I didn't want to confuse people who might be reading or worse, steer the thread...

I see your concern. I have been including US-centric information in my posts in part for a compare and contrast understanding of where the approaches are different and why, and the different strengths and weaknesses. So I think (and I hope others agree) that this can be a valid part of the discussion. If not, I will back off.
posted by bunnycup at 10:23 AM on January 22, 2010 [1 favorite]

But even assuming this medical/scientific journal is addressing government policy/insurance coverage (which it doesn't appear to me to be doing) putting in context against publicly funded healthcare in other countries, are those who carry heritable diseases (and whose children have a greater-than-average high likelihood of sickness or serious, costly illness) discouraged from reproducing? If ART is to be denied to smokers or obese women (but not men?) on these grounds, should it be denied to carriers of cystic fibrosis genes? Breast cancer genes? INI1 mutations? It seems to me the same logic could apply. It's a rhetorical question of course (and not meant to fully equate denial of reproductive assistance to eugenics), asked to point out how much more important the ethical questions are than the blinders approach of "government pays, government decides whether to cover". And that said, separate from the pre-conception cost of the procedures, if the intent is to protect the quality of life of the future child and limit government costs, these are long term questions and the health costs over a sick child's life dwarf the ART costs. Shouldn't the prohibitions then apply equally to fertile couples? Why should the rest of the population have to pay for their sick children? Again, completely rhetorical and not intended to be taken as a dead serious statement - I don't believe the restrictions should apply to any family.

I know these are meant to be rhetorical, but they're still worth looking at ethically. I don't think it's right to present all these as the same case in one moral category. The moral decisions of individuals are theirs and theirs alone, but cases involving medical intervention are perhaps different. It's possible to create examples in which most people would choose to deny reproductive assistance, or at least agree with a doctor's or state's decision to do so. If we accept a moral boundary exists, then we need to ask where it lies. I don't agree that inheritable illnesses or genes are good examples for finding that boundary though, as they can't count as an active moral decision on the part of the person who carries them. But other things do count as active moral choices, and I don't agree that it should be unusual to count them against the interests of the future child. This needs to be reasonable though, and accepting that the parents and the child will benefit, and that society bears a potential cost for all it's members regardless.

I want to agree to restrictions shouldn't apply to any person seeking reproductive assistance, but I don't know if that's true in every single case.

(Oh, please don't back off, this is an interesting discussion, with many threads.)
posted by Sova at 10:43 AM on January 22, 2010 [1 favorite]

I don't think it's right to present all these as the same case in one moral category.

I agree with you, completely. There are very much differences along a number of difference indices. I do not mean to imply that all are the same, or that there is an automatic/clear answer. Just, as you say, that exploring those types of questions philosophically gives insight onto the broader questions of whether there should be overarching principles that prohibit a doctor from allowing treatment for an individual patient. I wanted to throw out a lot of different questions for consideration.

I very much see differences among the appropriateness of (i) a rule that doctors are not permitted to provide ART to women who are, for example, obese, (ii) public/government insurance declining to pay for ART in some or all situations, and (iii) an individual doctor declining to provide ART to an individual woman based on her medical status, likelihood of success, etc. I want to make that clear, that my objection is to (i), and not (ii) or (iii).

One of my reasons for objecting to (i) above, a rule that doctors may not provide care in a given case, results from my consideration of examples I can think of where I would agree that the ability to reproduce should be withheld. In the rare case where I would agree with witholding the right to reproduce, the basis for that applies equally to fertile and infertile people. As a very general and off-the-cuff hypothetical I might be comfortable restricting the future reproductive rights of people convicted of serious child abuse. If people are deliberately harming children, I can understand not allowing them to have more children. But that problem - the harm caused by the choice - is equally applicable to those who reproduce in the normal way, so I am not comfortable with the prohibition applying exclusively to infertile couples(*).

Secondly, I think the difficulty and low success rates of ART in general somewhat act as a natural bar or limitation to the negative effects. To explain what I mean, in the US in 2007 35% of ART cycles resulted in a live birth. The process is expensive and unlikely to succeed, and families really are motivated to do what they can to improve their chances (says the woman who quit smoking, worked toward weight loss and started prenatal vitamins on January 1, 2010 in desperate hopes of doing IVF this year, on the advice of my fertility doctor). For that particular moral hazard, it seems self-correcting, in that doctors already counsel smoking cessation and the procedure is less likely to succeed as a result. I would think the general, long-term costs to society are far, far more damaging for smoking, drinking, drugs, etc. during an unassisted pregnancy where these issues are not self-correcting. In fact, with ART, I would argue that many women behave more healthily than in an unassisted pregnancy - I will have had no nicotine, high folate, high iron, and no prescription drugs for months before IVF, whereas my unassisted pregnancy was a surprise and I quit smoking and started vitamins after discovering I was pregnant. Anecdotal, obviously. (**)

But please note:
(*) I am not suggesting that we pursue a path of pre-licensing for reproduction. But I think the argument of restriction of ART based on long-term costs to society applies equally to both ART and unassisted pregnancy, and therefore I feel it is inequitable to apply the restrictions only to infertile couples. In my humble opinion, if the restrictions can't be equitably imposed, they should not be imposed.

(**) I realize that the low success rate is part of why folks have argued a separate issue, that regardless of whether ART is permitted in given cases, it should not be government funded. I am speaking to whether it is permitted, and I realize that the short term costs are high for a low likelihood of success. When I say it should be permitted, please do not interpret that to also mean that it should be paid for by the government. To me, permission and facilitation are two different issues.
posted by bunnycup at 11:24 AM on January 22, 2010 [1 favorite]

I think the obesity clause in the ESHRE statement is not medically and ethically water-tight, but they acknowledge that more work needs to be done. Take out the obesity section, and I think the rest of their provisions (no ART for smokers or drinkers) are absolutely morally justified.

Nicotine and alcohol are known teratogens which could cause harm and suffering to a potential child.

If people are deliberately harming children, I can understand not allowing them to have more children. But that problem - the harm caused by the choice - is equally applicable to those who reproduce in the normal way, so I am not comfortable with the prohibition applying exclusively to infertile couples

We can't stop people who drink and smoke from procreating if they are already fertile without the greater moral problem of intruding on their privacy. However, when the ART provider has a woman come to him/her who is "unwilling or unable" to stop drinking, he has the moral imperative to intervene just as if it were a case of potential child abuse. In that instance, there is nothing that trumps concern for the well-being of the potential child. In the case of the already-fertile alcoholic, there is.

I absolutely agree that if we counsel couples on lifestyle, it should apply equally to men and women, and that the moral issue is different from the payment issue. However, there is a pretty solid moral case for making a distinction between the rules we apply to the fertile and the infertile, and it has everything to do with the fact that another human (the healthcare provider) is entering into the decision process and takes some moral responsibility of their own.
posted by slow graffiti at 1:58 PM on January 22, 2010 [2 favorites]

In my humble opinion, if the restrictions can't be equitably imposed, they should not be imposed.

Just to be clear, you're saying that ethical guidelines for medical professionals should impose no restrictions on ART that would not also justify involuntary sterilization.

That is an extreme position to take. It is far more of an intrusion upon personhood to involuntarily sterilize someone than to refuse to fertilize their eggs for them. It matters a great deal -- legally, philosophically, ethically -- whether you are refusing to assist someone, on the one hand, or making changes to their body without their consent, on the other.
posted by palliser at 8:21 PM on January 22, 2010

Just to be clear, you're saying that ethical guidelines for medical professionals should impose no restrictions on ART that would not also justify involuntary sterilization.

Certainly not; I'm not sure where you got that. I did a word search and it didn't appear until your comment. As you see, you would feel it a gross intrusion to refuse to permit fertile people to reproduce. If there are to be medical ethical guidelines (or, legal ones) prohibiting infertile couples from reproducing, there should be medical ethical guidelines (or, legal ones) prohibiting the fertile couples from reproducing.

I realize you want to add drama to my position and are trying to neutralize it as "extreme", but the drama isn't there and there is really nothing new in asking that those who have a medical disease be treated equitably with those who don't. Nor is there anything new, at least in the United States, with the idea that if laws(*) can't be equitably - you noticed I said equitably, i.e. fairly, not equally, i.e. exactly the same? - imposed, they are not valid. As I've said above, I realize the ESHRE proposal is neither a law, nor in the United States. However, there are frequently proposals on the table to limit ART availability and my state (PA) recently convened a law committee to look at changing the laws for surrogate pregnancies. Further, as per CT law which governs my insurance and I linked above, the ethical requirements have some secondary/indirect legal effect as it pertains to insurance coverage.

However, when the ART provider has a woman come to him/her who is "unwilling or unable" to stop drinking, he has the moral imperative to intervene just as if it were a case of potential child abuse..

I don't think it's a reasonable analogy.

To take it a little further with your analogy to a physician's duty to intervene in a suspected case of child abuse, I see the situation proposed by the ESHRE guidelines differently, philosophically, in that the only cases addressed are cases where the parent brings the child to the pediatrician (i.e., comes in for fertility counseling). All those cases where the child doesn't bring the child to the pediatrician (i.e. those who become pregnant without medical assistance, smokes their lungs out and has a child), have no restrictions on their decision to do so. But, I realize there are limitations for that analogy, and for one I do not know whether or how CPS might get involved after the child is born and has health problems as a result of the parent's obesity, smoking and/or drinking. I realize that CPS or other authorities may often get involved in cases of fetal alcohol syndrome or drugs, but I haven't heard the idea that obesity or smoking in a mother is a sign of child abuse.
posted by bunnycup at 7:36 AM on January 23, 2010 [1 favorite]

If there are to be medical ethical guidelines (or, legal ones) prohibiting infertile couples from reproducing, there should be medical ethical guidelines (or, legal ones) prohibiting the fertile couples from reproducing.

I have no idea how you'd "prohibit fertile couples from reproducing" without involuntary sterilization. I realize you don't like the term "involuntary sterilization," but that's exactly what that means. You said earlier, "As a very general and off-the-cuff hypothetical I might be comfortable restricting the future reproductive rights of people convicted of serious child abuse. If people are deliberately harming children, I can understand not allowing them to have more children." With infertile couples, you could manage this by: not assisting their reproduction. With fertile couples, you can only manage this by: involuntary sterilization. That is what makes those situations very, very different.

And no, saying, "I won't help you do that" is not the same as "prohibiting" it. It's saying, "I won't be involved in it." You can do what you want, but those doctors feel ethically bound not to assist it, that's all. They have the right to their principles, too.
posted by palliser at 7:47 AM on January 23, 2010

Without trying to derail terribly, one of the issues that seems to be at stake with behavioral/health requirements for ART in the US is that women of higher SES who can seek out and afford ART are being treated in the same ways that poorer women and women of color are being treated by the legal and medical establishments. I'm not sure how to express this well, but I'm going to take a stab at it anyway.

Every so often we read about a judge who imposes birth control (or even sterilzation) on a woman, usually poor and/or minority, as a condition of staying out of jail for drug use or some other crime. To the extent that this Victorian judgement of fit motherhood is accepted for biological parents, it seems to be OK because the woman is somehow other and it's OK to identify her as a "bad mom" and therefore limit her reproductive rights.

A related issue is the medicalization and public authority now presumed about any aspect of pregnancy, where it's socially acceptable for people to question every aspect of a pregnant woman's decisions. For instance, any pregnant woman who has even a single alcoholic drink is subject to public opprobrium even though it's nobody's business but hers, her partner's, and her doctors. Similarly, women's eating choices (e.g., no sushi allowed), weight and exercise choices, etc. are all subject to special public criticism, and her medical decisions can be overridden by doctors for the good of her child (e.g., forced Cesareans).

In light of these trends, it seems to me that there's not a consensus that women really do have the moral right to control their own reproduction in a positive sense (to choose to become pregnant freely) any more than there's a consensus that women have a right to choose not to be pregnant (to abort or, according to some, to use birth control). Middle- and upper-class women in the US generally can use their money and social power to get better access to reproductive freedom; the move to limit ART to "deserving" women who aren't presumed overeaters, smokers, drinkers--all of which are behaviors that have a perceived negative moral dimension--is just extending visible and enforceable gatekeeping of reproductive rights to a group of women that has generally been exempt.

(This is all separate from the question of single-payer, where restrictions may also have to do with limited funding and difficult choices, such as paying for ART vs paying for treatment to save lives or mitigate chronic illnesses, which is a different set of moral and financial calculations.)
posted by immlass at 8:09 AM on January 23, 2010

Every so often we read about a judge who imposes birth control (or even sterilzation) on a woman, usually poor and/or minority, as a condition of staying out of jail for drug use or some other crime. To the extent that this Victorian judgement of fit motherhood is accepted for biological parents, it seems to be OK because the woman is somehow other and it's OK to identify her as a "bad mom" and therefore limit her reproductive rights.

This argument -- birth control as a condition of release because people see women as "other" -- is less convincing when you consider that in certain states, chemical castration may be imposed upon sex offenders as a condition of release. Those are almost always men.

The comparison to ART is flawed, to me, because the importance we place on bodily integrity -- legally, ethically -- is so great. I really don't think people are more willing to regulate ART than copulation-based pregnancy because they see it as the thin end of the wedge in regulating women's right to reproduce; they are more willing to do it because it doesn't involve invading someone's bodily integrity, which is generally distasteful.
posted by palliser at 8:34 AM on January 23, 2010 [1 favorite]

I have no idea how you'd "prohibit fertile couples from reproducing" without involuntary sterilization. I realize you don't like the term "involuntary sterilization," but that's exactly what that means. You said earlier, "As a very general and off-the-cuff hypothetical I might be comfortable restricting the future reproductive rights of people convicted of serious child abuse. If people are deliberately harming children, I can understand not allowing them to have more children."

I don't think you could and therefore, as I said above, you shouldn't take away anyone's reproductive rights. It's in the very same comment you quoted. With a little star next to it, linking it with the comment you copied. Furthermore, you included a copy of the words "hypothetical," which my statement was. I've said more than once, that I am arguing against taking away anyone's reproductive rights. No worries that you have missed it, I absolutely realize you can't read and absorb and attribute every word said in the thread, and that I write wordy, dense, long, strident and off-putting, boring sentences. I know this about myself.

You can do what you want, but those doctors feel ethically bound not to assist it, that's all. They have the right to their principles, too.

What if their principles persuade them that they don't want to be involved in interracial reproduction, or reproduction of minorities at all? Or families in poverty (who, granted, may have a practical bar as it is for cost, but suffer no prohibition)? IVF with donor sperm or egg in same-sex couples (currently prohibited in some places, with that prohibition often objected to)? Assisted reproduction for people with heritable diseases or legal disabilities? I don't think it's an accurate statement, at least in the United States, to propose that doctors can refuse medical treatment for a disease whenever their principles - no matter how egalitarian or not - dictate otherwise. Emergency room doctors are obligated to provide equal treatment to criminals. Sure, the medical profession has no obligation to provide assisted reproduction at all, I guess (except that infertility is a disease that can often be cured and I thought that curing disease was the point of the medical profession), but if they do, I do believe they have to provide it equitably and without *inappropriate* discrimination.

And no, saying, "I won't help you do that" is not the same as "prohibiting" it.

Please re-read this, from my last comment:

"As I've said above, I realize the ESHRE proposal is neither a law, nor in the United States. However, there are frequently proposals on the table to limit ART availability and my state (PA) recently convened a law committee to look at changing the laws for surrogate pregnancies. Further, as per CT law which governs my insurance and I linked above, the ethical requirements have some secondary/indirect legal effect as it pertains to insurance coverage."

In case that wasn't clear enough, which I guess it wasn't, my fear is based on the fact that I already have a precedent, the CT insurance law, for a state adopting a body's ethical guideline as some aspect of law (in the CT law, not a prohibition, but a limitation of coverage). If a state were to adopt ethical guidelines as law (something that is sometimes talked about in different ways) that were the same as or similar to ESHRE, that would be a legal prohibition.

As a better example, there have been proposals to limit the number of embryos that can be implanted in a given procedure, to prevent cases of high-order multiples. For example, such a law would have prohibited Suleman from implanting 6 embryos and having the octuplets. High order multiples have health problems, and I agree that fertility doctors need to practice careful ethics in deciding how many embryos to implant. But, when embryo's are lower grade and with advanced maternal age, it might be appropriate to implant more embryos than in a young woman of good health and presumed fertility, like me. I don't disagree with my doctor's decision to tell me that our clinic would not implant any more than 2 at a time, for me. I would strenuously oppose a law that prohibited the implantation of more than 2 embryos at a time. I would strenuously oppose the adoption of broad guidelines that said no more than 2 at a time should be implanted. It is a decision for the doctor and patient, that absolutely must be informed by ethics, but those ethics are drawn from appropriate treatment decisions.

I also said above, that I was not equating the denial of reproductive assistance to eugenics, by which I meant that I accept that unavailability if IVF is not the same as sterilizing people with undesirable traits. I said this because I don't think that - sterilizing people who we don't want to have reproduce - is appropriate either.
posted by bunnycup at 8:43 AM on January 23, 2010 [1 favorite]

This argument -- birth control as a condition of release because people see women as "other"

I didn't say that at all. I said there was a notion that women don't have the right to control their own reproduction and that birth control as a symptom of release was an expression of the right of someone else--in this case the legal system--to control it for them because they're unfit to make that decision for themselves. Chemical castration just extends the argument that there's a perceived public interest in limiting or promoting reproduction to men.

I really don't think people are more willing to regulate ART than copulation-based pregnancy because they see it as the thin end of the wedge in regulating women's right to reproduce

I see the cause and effect the other way around: people are willing to regulate ART because they already feel like they have a public interest in promoting "good" reproduction and limiting "bad" reproduction. ART is just easier to regulate, or to swallow the regulation of, because regulating it conflicts less with other competing values, like bodily integrity.

I'm not trying to argue that regulation of ART or a physician code of practice is a good or bad thing, or about the financial issues involved; I'm locating it in a set of public policies and social policy impulses about reproduction, morality, and eugenics. ART isn't a single-dimension issue.
posted by immlass at 8:53 AM on January 23, 2010 [1 favorite]

I see the cause and effect the other way around: people are willing to regulate ART because they already feel like they have a public interest in promoting "good" reproduction and limiting "bad" reproduction. ART is just easier to regulate, or to swallow the regulation of, because regulating it conflicts less with other competing values, like bodily integrity.

I absolutely agree with this, and think it is very well said. I'm not going to expand or go further on it, because I think it is just a clear, meaningful, well-put statement. I don't want to beat it into the ground, as I inevitably will.

I'm locating it in a set of public policies and social policy impulses about reproduction, morality, and eugenics. ART isn't a single-dimension issue.

Yes.
posted by bunnycup at 8:59 AM on January 23, 2010

I don't think you could and therefore, as I said above, you shouldn't take away anyone's reproductive rights.

Well, so, we're pretty much back to my earlier characterization of your opinion: "you're saying that ethical guidelines for medical professionals should impose no restrictions on ART that would not also justify involuntary sterilization." It's just that you also think involuntary sterilization is effectively never justified, and so neither should restrictions on ART be.

Again, this strikes me as extreme, in that it's failing to recognize the morally valent fact that regulating ART doesn't involve invading bodily integrity, and therefore can be approached with less hesitation than involuntary sterilization.
posted by palliser at 12:21 PM on January 23, 2010

I'm coming back in simply to restate some basic points that it appears some people are blind to in the debate above.

1) The principle of respect for people's autonomy over their own bodies. This includes autonomy over their fertility and respecting their right to carry pregnancies to fruition or to terminate them. While people are encouraged to think seriously about reproduction and methods of contraception are provided, any moves towards outside control (such as the current fad of 'idiocracy') are deplored for contravening this basic principle.

2) Rejection of the term 'reproductive rights' in the debate about provision of ART. Reproductive rights properly belongs in a discussion about the one-child policy in China where women have been restricted in their natural ability to reproduce. It has no place in a situation where people are not being restricted, simply declined assistance to reproduce.

3) Respect for the principle that when people are asked for assistance (in this case for reproduction assistance), the helpers have the right to set the terms on which they will give assistance. This includes their setting guidelines for where they will assist or not assist on the basis of their own moral and other (e.g. financial) judgements.
posted by Pranksome Quaine at 1:54 PM on January 23, 2010

Respect for the principle that when people are asked for assistance (in this case for reproduction assistance), the helpers have the right to set the terms on which they will give assistance.

This is the line of discussion that proves beyond a doubt ART is absolutely a reproductive rights issue. It's the exact same conscience/morals argument that anti-abortion-rights doctors and pharmacists use to refuse birth control or abortion services or even referrals for those services to women seeking them. A major issue with ART (as with abortions, birth control and other reproductive rights) is determining where the rights of doctors and providers to determine how they will treat patients conflict with the rights of patients and those seeking treatment.

I understand your arguments, Pranksome Quaine. You're just wrong on two of your three counts.
posted by immlass at 2:17 PM on January 23, 2010

(palliser) It's just that you also think involuntary sterilization is effectively never justified, and so neither should restrictions on ART be.

Exactly.

Yes, I absolutely think they are unjustified. Like I said, if an individual doctor and an individual patient are consulting, it's one thing, but an overarching rule that takes away the reproductive rights of obese women? Yeah. I approach someone taking my reproductive rights away with equal apprehension as you might, and view it as an objectionable invasion of my privacy. That someone feels it is, essentially, just different because I need help and you (general/editorial you) don't, could not be less persuasive; it's not acceptable grounds for discrimination in other situations, and reproduction is a fundamental right. Further, as an example of the flaw in your reasoning, a refusal to provide, say, chemotherapy for cancer to certain people is not a compromise of bodily integrity. "Doctors should not provide chemotherapy to obese people" or "Doctors should not provide ED treatment to men with STDs" would be pretty universally objected to, even though those things don't involve an invasion of bodily integrity. Current dominant medical thought considers infertility a disease, just like cancer, or erectile dysfunction, or TB and so on.

(Pranksome Quaine) 3) Respect for the principle that when people are asked for assistance (in this case for reproduction assistance), the helpers have the right to set the terms on which they will give assistance. This includes their setting guidelines for where they will assist or not assist on the basis of their own moral and other (e.g. financial) judgements.

Pranksome Quaine, I think I can reasonably suggest that US law doesn't support your claim, and in addition it's not fully thought out and inappropriate (as an example; chemotherapy is assistance with a disease; a wheelchair is assistance with a disability). Where do you draw the line between unnecessary 'assistance' and medical 'treatment'? I can tell you where other ART ethicists/doctors draw it. The American Society for Reproductive Medicine says "Infertility is NOT an inconvenience; it is a disease of the reproductive system that impairs the body's ability to perform the basic function of reproduction. " Also, immlass said it far better than I could, so I defer and agree.
posted by bunnycup at 4:52 PM on January 23, 2010

It's the exact same conscience/morals argument that anti-abortion-rights doctors and pharmacists use to refuse birth control or abortion services or even referrals for those services to women seeking them.

There are few people who would argue that doctors should not be permitted to exercise some restraint on abortion services according to their own ethical principles. I can think of a couple of jurisdictions where there are no legal restrictions on abortion (New York, Canada), and yet, you cannot get a third-trimester abortion in either of these places without certain medical reasons. That is because no doctor will perform such an abortion. Is it your argument that they should be required to do so? If you impose such a requirement, you'll soon be running very short on abortion doctors.

Medical professionals set ethical guidelines that may restrict treatment options, in a variety of cases.
posted by palliser at 9:12 PM on January 23, 2010

I can think of a couple of jurisdictions where there are no legal restrictions on abortion (New York, Canada), and yet, you cannot get a third-trimester abortion in either of these places without certain medical reasons. Is it your argument that they should be required to do so?

I was not the person arguing for an absolute and unrestricted right to reproduce with ART.

Rights are effectively defined by their limits: your right to swing your fist ends at my nose. A doctor's absolute right to choose their patients and select a course of treatment (or refuse to provide certain treatments) may be in conflict with a patient's right to be treated as they choose. Neither set of rights is or should be absolute.

Medical professionals set ethical guidelines that may restrict treatment options, in a variety of cases.

The question we're debating is locating an appropriate context for those ethical guidelines, particularly ethical guidelines for ART. Reasonable people can differ on that context and its application to individual cases.
posted by immlass at 10:01 PM on January 23, 2010

There are few people who would argue that doctors should not be permitted to exercise some restraint on abortion services according to their own ethical principles. I can think of a couple of jurisdictions where there are no legal restrictions on abortion (New York, Canada), and yet, you cannot get a third-trimester abortion in either of these places without certain medical reasons. That is because no doctor will perform such an abortion. Is it your argument that they should be required to do so? If you impose such a requirement, you'll soon be running very short on abortion doctors.

I think that analogy fails because here, we are not talking about a doctor's decision whether to provide ART. Certainly a doctor may decline to be a doctor that provides abortion, that provides late-term abortion, that provides ART, that provides IVF. What you are talking about are doctors' rights to decide not to provide a given procedure to anyone; essentially, a doctor's right to decide what area of practice to pursue. Agreed, no individual can be forced to become a fertility doctor rather than an oncologist. What I am talking about is fertility doctors who currently do provide these procedures to the public, and whether a decision not to provide them under terms like those in ESHRE would be discriminatory. A doctor may decide not to provide late term abortions; but if he provides them, he must not act with discrimination in patient care.

Further, a number of bodies limit the ethical rights of a doctor to refuse care in various situations. Certainly no one (including myself) says a doctor must always provide care to every patient that knocks on her door. But, there are generally rules governing how the termination of a doctor-patient relationship or the refusal to provide certain services is handled.

For example, here is an article about medical ethics in the United Kingdom:

"Not everyone is likable but we must try to avoid discrimination. Some people have a life-style that is not to our liking. Perhaps they are smokers, obese, travellers, drug addicts, unwashed, with a sexual orientation of which we disapprove, or perhaps they hold strong religious or political opinions that disturb us. If their life-style is such that it is deleterious to their health we may and should discuss the errors of their ways. Try to be helpful rather than judgemental. We should not refuse treatment purely on those grounds unless evidence-based practice shows that the intervention is useless unless they change their ways."

Here's another one, stating "Never discriminate unfairly against patients or colleagues." Here's more (also from the General Medical Council UK):

18. You must not allow any personal views that you hold about patients to prejudice your assessment of their clinical needs or delay or restrict their access to care. This includes your view about a patient's age, colour, culture, disability, ethnic or national origin, gender, lifestyle, marital or parental status, race, religion or beliefs, sex, sexual orientation, or social or economic status.

The American Medical Association has a list of reasons care can and can't be declined, here. The AMA seems to take the approach than an individual doctor is not required to take on any particular individual patient (I don't disagree), but that patients, once taken on, cannot be discriminated against. Also, as I copied above, the ASRM has ethical guidelines as well. Here is a paper pertaining to the management of obesity in ART patients, which recommends treatment of the obesity but I do not see a clause permitting denial of services to the obese. As addressed in detail early in this thread, obesity is a side effect of one of the most common causes of infertility.

The purpose of all of this is to underscore my point, which is that the ESHRE guidelines constitute discrimination. As a technical matter, I am sure that when a doctor is bound by two ethical guidelines (say, a generic one and one geared to his type of practice) there are protocols for resolving inconsistencies and determining how to act. But, more philosophically, I am saying that guidelines that refuse care to infertile women (but not fertile women, infertile men or fertile men) based on lifestyle factors are discrimination, and I consider them unethical.
posted by bunnycup at 6:19 AM on January 24, 2010

Thank you for digging up those links and excerpts bunnycup that address my point 3. Very useful to see. This has been a good discussion and I think we've teased out some interesting points and given a good display of the range of views on these matters.
posted by Pranksome Quaine at 7:01 AM on January 24, 2010

A doctor may decide not to provide late term abortions; but if he provides them, he must not act with discrimination in patient care.

Well, the question is whether he's discriminating on the basis of valid medical concerns -- patient safety, or potential damage to a third party -- or on the basis of invalid concerns, such as whether the doctor likes "people like that." In the case of late-term abortion doctors, you'll actually find that they do "discriminate," in the sense that they'll turn women away if their reasons for seeking an abortion make the doctor feel that the procedure would be unethical to perform.

Smoking and drinking are lifestyle choices, certainly, but they're not merely lifestyle choices; they're also significant dangers to the fetus the doctor will be placing in the womb (and here, this must be distinguished from abortion, in that this fetus will live to become a full person, with potentially severe damage related to those lifestyle choices). In a way, the doctor will have placed this person in a known danger, and to me, it seems reasonable for the doctor to draw the line there -- to say that these dangers are too great to be involved with.

In other words, if a woman has a habit of drinking 5 drinks a day and she conceives and bears a child with fetal alcohol syndrome, that's on her. If a doctor knows she has this habit and helps her conceive and she bears a child with fetal alcohol syndrome, that's on him, too. I don't see how you can insist (1) that he has a responsibility to help her conceive, and (2) that if he refuses, he's indulging his lifestyle prejudices through unfair discrimination!

I'd like also to give a better comparison to illustrate my bodily integrity point. Ethical guidelines in some countries constrain ART doctors from placing more than a certain number of embryos in a womb, because the risk of birth defects goes up the more fetuses there are in a womb. So even if a woman asks to have 6 embryos placed, to raise the chances of successful implantation, the doctor may refuse to do more than 2, based on ethical guidelines. On the other hand, if the doctor places 2, and they both split into triplets, the doctor may not order selective reduction, against the mother's wishes. This is where the importance of bodily integrity becomes clear. Both of these determinations would have the same effect, in terms of her ability to exercise completely unfettered reproductive rights: the result of either would be that she is not permitted to have 6 embryos in her at once. But because enforcing one involves refraining from invading her body, and the other involves invading her body against her wishes, the former is acceptable, and the latter is not.

To me, this is exactly why it's okay to refuse to place a fetus in the womb of a heavy drinker, but not okay to involuntarily sterilize a heavy drinker. It's different, in the same way that ethical guidelines restricting the number of embryos that can be placed through ART is different from involuntary selective reduction.
posted by palliser at 10:50 AM on January 24, 2010

Smoking and drinking are lifestyle choices, certainly, but they're not merely lifestyle choices; they're also significant dangers to the fetus the doctor will be placing in the womb (and here, this must be distinguished from abortion, in that this fetus will live to become a full person, with potentially severe damage related to those lifestyle choices). In a way, the doctor will have placed this person in a known danger, and to me, it seems reasonable for the doctor to draw the line there -- to say that these dangers are too great to be involved with.

This is the sort of thing that I'm talking about when I talk about "good" and "bad" pregnancies and the perceived public interest in reproductive health. I'm not saying that there's no validity to concerns about drinking and smoking, but realistically these things happen along a continuum. There are women who drink 5 glasses of whiskey every day, and sure, they're a bad bet to produce a healthy child. But the social opprobrium, in the US at least, for women who drink even so little as a single glass of wine during pregnancy is very high; people don't consider the idea that she may have discussed having a glass of wine with her doctor who may have OKed one glass once.

I've had arguments with lay people who have outright told me that having any drinks at all during pregnancy is essentially unconscionable negligence and a huge moral failure on the part of the pregnant woman, as if there's no difference between one drink once and five a day throughout a pregnancy. That's not about medical issues; that's about a perceived public interest in the contents of women's wombs. It's also about the moral failures of the pregnant women who don't visibly put their fetuses/unborn children first, specifically by complete abstention from alcohol.

I'm not arguing that there's no line at all to be drawn for medical reasons, including the medical consequences of lifestyle choices. Nor am I saying that there's no place for ethical decisions on the part of doctors. I'm just saying that if you miss out talking about how people already feel like they have a public interest right to dictate the behavior of women who are trying to reproduce, you're missing out on a big dimension of the ethical debate.
posted by immlass at 12:04 PM on January 24, 2010

I don't see how you can insist (1) that he has a responsibility to help her conceive, and (2) that if he refuses, he's indulging his lifestyle prejudices through unfair discrimination!

Yes, I believe it is discrimination to refuse treatment for discriminatory reasons. In terms of whether these issues (smoking, drinking, obesity) are reasons for which the denial of care constitutes unfair discriminition, yes, in common with the ethical bodies surveyed above, I believe they are. That is, I define inappropriate discrimination not really any differently than the 3 professional association ethics guidelines linked above. The ASRM, AMA and UK ethics guidelines I linked above seem consistent with my view.

I don't see how you can insist that a doctor does not have a responsibility to perform his or her job without unfair discrimination. That view seems supported neither by (US) law nor by medical ethics.

So even if a woman asks to have 6 embryos placed, to raise the chances of successful implantation, the doctor may refuse to do more than 2, based on ethical guidelines

I already addressed this, above, so I'll just refer you back.

Palliser, it seems to me that you are arguing for individual doctor autonomy to refuse treatment and you are using the autonomy you perceive exists as a data point in support of guidelines that abrogate precisely that same individual doctor autonomy. That is, as I read your comments, you seem to be saying "An individual doctor has the right to refuse treatment, therefore guidelines that force an individual doctor to refuse treatment are okay". I see that as flawed for two reasons. First, I disagree that doctors have that autonomy to the extent you assert, and my disagreement is supported by the medical ethics governance rules opinions I read and linked above. Secondly, even if individual doctors have the autonomy to deny certain treatments to certain individuals for any reason (*), it does not follow that the blanket denial of care for lifestyle reasons without regard to individual patient/doctor ethics is appropriate.

I am arguing the opposite. It is not okay to make a blanket rule denying care to obese, smoking, drinking women. But if an individual doctor making an individual treatment plan with a particular family feels they can't provide care (and there is a medical, permissible, non-discriminatory reason for it), that's different. These ethics rules don't give an individual doctor the chance to make his own judgment.

(*) I have said this above, throughout this thread including in the embryo example I linked back to, but will say again that I certainly admit there are situations where a doctor can and should make a medical decision to stop or not provide certain treatment. My daughter's oncologists made a medical decision that no more chemo treatment or surgery would reasonably benefit her. I understand how, when and why doctors may legitimately decide to stop or to not provide treatment. But, I agree with the AMA, ASRM, etc., that there are limits on the reasons for which doctors can deny care; and that obesity and lifestyle choices are outside of those limits.

On preview, I want to build on something immlass is suggesting with regard to drinking during pregnancy. While I was pregnant, studies came out suggesting that a higher alcohol intake than was previously thought might be permissible during pregnancy. I happened to have 2 obstetricians because I moved in the middle of the pregnancy. My first OB was opposed to any drinking at all during pregnancy (and also told me to stop dying my hair). My second OB said occasional and limited drinking, for example 2-3 glasses of wine per week but no more, was acceptable (and no limits on hair dying). The study that came out while I was pregnant suggested that it would take regularly drinking 7-8 times per week to cause damage. Who is right? Should individual doctors be able to make individual decisions for their patients, in their practice? I don't know who is right, but I know that a blanket opinion saying "treatment should be refused for women who won't stop drinking during pregnancy" is not consistent with my second OB's and the more recent medical literature's advice. Point being, there is room for reasonable minds to differ.
posted by bunnycup at 12:33 PM on January 24, 2010

I already addressed this, above, so I'll just refer you back.

You addressed the fact of guidelines limiting embryo placement, but not my point, which was: is refusal to implant 6 embryos in, say, a 23-year-old woman the same thing as forcing a 23-year-old woman to undergo selective reduction? If not, I submit that the reason it's different is the same reason it's different to refuse to perform ART than to involuntarily sterilize someone. And that is the reason doctors (and their professional ethics associations) can regulate ART in cases where involuntary sterilization would be wrong.

The guidelines specifically regarding obesity and ART are useful, thanks. And I wouldn't be surprised to learn that obesity does not pose significant enough a risk to deny treatment on that basis, or that this is really unfair discrimination masquerading as an appropriate interest in ensuring the health and safety of the patient and the resulting baby.

But the other links refer only to "invidious" or "unfair" discrimination. That's begging the question, as the whole topic here is whether it's appropriate to discriminate between smoking and non-smoking, drinking and non-drinking, in the same way it's appropriate to discriminate between a 93-year-old and a 39-year-old when deciding whether to perform surgery -- namely, that the probability of success of the medical outcome (here, not only a baby, but a healthy baby) depends on it.
posted by palliser at 7:21 PM on January 24, 2010

If not, I submit that the reason it's different is the same reason it's different to refuse to perform ART than to involuntarily sterilize someone.

No one, not one single person, has suggested they aren't different. But they don't need to be different for any of my objections to apply, whatsoever. I said that the first time, and each and every subsequent time, you raised the sterilization issue. It is just as much a red herring now, as it was then. Not one of my objections rests on the premise that these things are the same. I object to discriminatory refusal of ART NOT AT ALL because it is like sterilization, but because it is wrong on it's face. That sterilization is also wrong is irrelevant. Lots of other things are wrong, too, but they don't make unethical discrimination in medical treatment any less wrong. It seems to me that you are saying involuntary sterilization would be wrong, and the refusal of ART is not involuntary sterilization therefore it is acceptable. That it is not "as bad as" or even coequal with sterilization is not sufficient.

"Today's deprivation of reproductive opportunity is compared to the coercive sterilization tactics of yesteryear, reminding us that seemingly well-meaning expressions about the welfare of the human race may be a pretext for nefarious social engineering aspirations."(*)

The above is from a legal journal article, which I found when it was cited by an ethics opinion issued by the American Society for Reproductive Medicine. I am not able to read the full article, but I was interested to see this summary. I am certainly not calling it a smoking gun nor arguing for its conclusion (because I haven't read it and therefore I don't know whether I agree with it). That article comparing sterilization and refusal of ART is by a woman who is a law professor and doctor, the chair of a medical school, and on the medical school's ethics committee. She has published frequently on ethics in ART. As only a summary, it's persuasive impact here is obviously very limited, and I recognize that, but it's nevertheless interesting.

But the other links refer only to "invidious" or "unfair" discrimination. That's begging the question

Absolutely not, insofar as I specifically stated (and provided materials to support) that I consider the ESHRE inappropriately discriminatory. I know I am way, way too wordy but one of the ethics opinions I attached (this one) specifically addressed whether treatment should be refused for each of smoking, drugs and obesity. Another stated that a doctor's personal opinions about a patient's "lifestyle" could not be used to delay or restrict access to care. That is, I used professional medical ethics opinions as a basis supporting my decision to place smoking, drinking, drugs and obesity in a class of characteristics for which discrimination is unfair.

... discriminate between a 93-year-old and a 39-year-old when deciding whether to perform surgery -- namely, that the probability of success of the medical outcome (here, not only a baby, but a healthy baby) depends on it.

The topic here is not whether an individual physician would make a different decision for a 93 year old patient or a 39 year old patient. These ethics guidelines take the decision away from the physician. They are much closer to "doctors are not allowed to provide the surgery for 93 year old patients." Again, I don't object to a physician making individualized treatment recommendations for individual patients. To illustrate: I seek ART because I had a hysterectomy but still have my ovaries. If my continued testing shows that my ovaries are not producing eggs, of course my fertility doc should notify me and might reasonably decline to provide ART because it would not be reasonably possible if I am not producing eggs. That is wholly distinguishable from a case of ethical guidelines saying "ART should not be provided to women who have had hysterectomies". The ESHRE are more like the latter than the former.

Not intending to put words in your mouth, but I respectfully think you are misinterpreting me and thinking that I am suggesting a doctor is obligated to provide care in every case whether or not it would work or is even physically possible, based on a patient's demand for it. That is not an accurate characterization of my point of view. ESHRE reduces individual doctor/patient autonomy, I argue to leave those decisions in the patient/doctor hands.
posted by bunnycup at 8:12 PM on January 24, 2010

It just burns me up.

Do they refuse covered treatment for alcoholics?
Do they refuse diabetes treatment for obese people?
Do they refuse treatment for the herioin addict in the ER? No one made that person shoot up but hey, if they have insurance, they're covered--medically and with rehab.

Then stay out of my reproductive choices because I'm, OMG 38!!! And drinking? I drank during my off cycles and as soon as we were ready to get treated, I abstained for a week prior and didn't drink until I got a negative and didn't do jack when I was pregnant out of fear of loss.

It's bad enough only 15 states have coverage for infertility treatments. We don't need more restrictions because of age, etc. I think those who are seeking infertility treatments are less likely to smoke, drink, etc. because they want this baby more than anything. And no one is denying mothers who do drink, smoke, etc. and didn't go through infertility treatments?

I guess why all the picking on infertility patients? Isn't this whole argument based on the mighty power the docs have over us? It's like saying "ok I have the power to get you pregnant---IF you're worthy."

Well whose worthy? And who gets the right to say who is? I sure don't want to be judged.

I still want an answer about why Viagra is given to anyone for any reason (unless there is a cardiac history). Why is something of "hey I just want to have lots and lots of sex, give me samples" ok and/or covered?
posted by stormpooper at 8:35 AM on February 11, 2010

I think the ethic committee should focus more on topics like gender selection for non-medical needs.

A friend got pregnant on the first try. I tried a year and had to go down the infertility route. She wanted a girl. I wanted whatever was healthy. She didn't get what she wanted and was pissed. She said she will go down the IVF gender selection route on the next kid.

I was never so hurt, offended, and angry in all of my life. People who think infertility treatments is this happy, works like a charm, all is great and dandy are highly misinformed and need to be denied coverage. Not people with age or obesity, etc.
posted by stormpooper at 8:43 AM on February 11, 2010