Jean Benward

Mandatory counseling for gamete donation recipients: ethical dilemmas

Mental health professionals have engaged in mandatory pretreatment counseling and assessment of patients seeking treatment at IVF programs in the United States since the 1980s. At present, most recipient patients undergoing IVF with egg or embryo donation in the United States are required to meet with a mental health professional for one pretreatment session. Mandatory counseling of gamete recipients is fraught with ethical questions for the mental health professional. Attention to issues of autonomy, confidentiality, role clarity, along with self-evaluation and openness with the patient can help lessen the impact of these ethical challenges.

Transferring embryos with genetic anomalies detected in preimplantation testing: an Ethics Committee Opinion

Patient requests for transfer of embryos with genetic anomalies linked to serious health-affecting disorders detected in preimplantation testing are rare but do exist. This Opinion sets out the possible rationales for a providers decision to assist or decline to assist in such transfers. The Committee concludes in most clinical cases it is ethically permissible to assist or decline to assist in transferring such embryos. In circumstances in which a child is highly likely to be born with a life-threatening condition that causes severe and early debility with no possibility of reasonable function, provider transfer of such embryos is ethically problematic and highly discouraged.

Provision of fertility services for women at increased risk of complications during fertility treatment or pregnancy: an Ethics Committee opinion

This opinion addresses the ethics of providing fertility treatment to women at elevated risk from fertility treatment or pregnancy. Providers ethically may treat women at elevated risk provided that they are carefully assessed; that specialists in their medical condition are consulted as appropriate; and that patients are fully informed about risks, benefits, and alternatives, including oocyte and embryo donation, use of a gestational surrogate, not undergoing fertility care, and adoption. Providers also may conclude that the risks are too high for them to treat particular patients ethically; such determinations must be made in a medically objective and unbiased manner and patients must be fully informed of the decision. Counseling of women who wish to initiate fertility treatment with underlying medical conditions that confer increased risk during treatment or pregnancy should incorporate the most current knowledge available, being cognizant of the womans personal determinants in relation to her reproductive desires. In such a way, both physician and patient will optimize decision making in an ethically sound, patient-supportive context.

Financial compensation of oocyte donors: an Ethics Committee opinion

Financial compensation of women donating oocytes for infertility therapy or for research is justified on ethical grounds and should acknowledge the time, inconvenience, and discomfort associated with screening, ovarian stimulation, and oocyte retrieval, and not vary according to the planned use of the oocytes, the number or quality of oocytes retrieved, the number or outcome of prior donation cycles, or the donors ethnic or other personal characteristics. This document replaces the document of the same name, last published in 2007 (Fertil Steril 2007;88:305-9).

Cross-border reproductive care: an Ethics Committee opinion

Cross-border reproductive care (CBRC) is a growing worldwide phenomenon, raising questions about why assisted reproductive technology (ART) patients travel abroad, what harms and benefits may result, and what duties health-care providers may have in advising and treating patients who travel for reproductive services. Cross-border care offers benefits and poses harms to ART stakeholders, including patients, offspring, providers, gamete donors, gestational carriers, and local populations in destination countries. This document replaces the previous document of the same name, last published in 2013 (Fertil Steril 2013;100:645-50).

Using family members as gamete donors or gestational carriers

The use of adult intrafamilial gamete donors and gestational surrogates is generally ethically acceptable when all participants are fully informed and counseled, but consanguineous arrangements or ones that simulate incestuous unions should be prohibited. Adult child-to-parent arrangements require caution in order to avoid coercion, and parent-to-adult child arrangements are acceptable in limited situations. Programs that choose to participate in intrafamilial arrangements should be prepared to spend additional time counseling participants and ensuring that they have made free, informed decisions. This document replaces the document of the same name, last published in 2012 (Fertil Steril 2012;98:797-803).

Child-rearing ability and the provision of fertility services: an Ethics Committee opinion

Fertility programs may withhold services from prospective patients on the basis of well-grounded reasons that those patients will be unable to provide minimally adequate or safe care for offspring. This document was reviewed and updated; this version replaces the previous version of this document, last published July 2013 (Fertil Steril 2013;100:50-53).

Informing offspring of their conception by gamete or embryo donation: an Ethics Committee opinion

This document discusses the ethical implications of informing offspring about their conception using gamete or embryo donation. It replaces the 2013 ASRM Ethics Committee document of the same name (Fertil Steril 2013;100:45-9).

Donor-conceived children: the view ahead

Sir, In response to the opinion expressed in Pennings (2017), ‘Disclosure of donor conception, age of disclosure and the well-being of donor offspring,’ we support the arguments of Crawshaw et al. and present an alternative opinion to that posed by Pennings. Pennings asserts that there is insufficient evidence on which to base the recommendation that parents share the use of donor gametes with their children. Further, he argues that mental health professionals make this recommendation based not on evidence, but on their own morals, and that such moralsbased advice violates the general principles of non-directiveness and respect for autonomy. The essential problem we see with Pennings’ view is that he ignores the major scientific advances emerging from the Human Genome Project in 2003 and the growth of direct-to-consumer (DTC) genetic testing (Harper et al., 2016; Phillips, 2016). In their recent Human Reproduction paper, Harper et al. highlight the exponential growth in the number of people using DTC genetic testing and the centralization of genetic information in large worldwide DNA databases. Thus, at any point in their life, a donor-conceived person can order a simple, inexpensive saliva DNA test and learn that their DNA does not match their presumed ancestry, putting into question their genetic relatedness to their parents. Furthermore, with the emergence of genome-based personalized medicine, it is anachronistic to propose that donor-conceived people will not obtain information about their DNA and its medical relevance. These scientific advances render untenable the assumption that it is solely the parent’s choice to determine whether their child learns of their donor origins. Given that it is unrealistic to believe that secrecy can be maintained throughout the lifespan of a donor-conceived person, Pennings’ arguments about whether existing psychological evidence indicates that disclosure or nondisclosure is better for children seem irrelevant and should be replaced by questions about how potential inadvertent disclosure will affect parents and families. The field of reproductive medicine should no longer practice gamete donation under old, now faulty assumptions about the viability of secrecy as an option for parents. We should consider that it is our duty to offer information and guidance to prospective parents about the likely possibility that regardless of whether they share the use of gamete donation with their child, the child may discover it anyway. We object to Pennings’ portrayal of mental health professionals as counseling about disclosure based solely on their ‘moral convictions.’ On the contrary, it is our view that when parents are provided with carefully delivered and complete information, it remains the parents’ choice how, when and even whether they want to address the topic of gamete donation with their child. Our clinical experience tells us that a parent’s comfort with the idea of sharing the details of their child’s conception is dependent on whether their fears have been addressed (Daniels et al., 2007). Two common fears are that their children will reject them or will consider their donor as a parent. Mental health counseling serves intended parents by addressing these fears and by laying out the different scenarios and difficulties that may occur with both disclosure and nondisclosure. We have found that this discussion is often a response to unmet needs expressed by the parents themselves. The task of a mental health professional is not to make moralistic arguments about what is best for children, but it is certainly not to guide parents in how to lie to their child, as was suggested by Pennings. Our task is instead to help prospective parents grapple with the reality that choosing donor conception has implications for their family and child that may be unforeseen at the time of conception.

Disclosure of medical errors involving gametes and embryos: an Ethics Committee opinion

Medical providers have an ethical duty to disclose clinically significant errors involving gametes and embryos as soon as they are discovered. Clinics also should have written policies in place for reducing and disclosing errors. This document was reviewed and affirmed in 2015 and replaces the earlier document of the same name (Fertil Steril 2011;96:1312-4).