There aren’t too many tabloid stories that have implications for science and medical ethics. But in January 2009, the sensational saga of Nadya Suleman, the mother of octuplets crudely dubbed Octomom, simultaneously lit up the TMZs and National Enquirers of the world and posed tough questions to the field of assisted reproduction. Methods such as in vitro fertilization and artificial insemination have been a miracle for many families who would not otherwise have been able to conceive their own children. But B.O. (Before Octomom) little attention had been paid, at least publicly, to the question of when assisted reproduction should and should not be offered to a patient.
Suleman, who was a single mother of six even before in vitro fertilization led to the rare occurrence of octuplets, was an extreme example, to be sure. Many physicians spoke out against the use of assisted reproduction in Suleman’s case, and the Beverly Hills doctor that provided the treatment was charged with gross negligence by the Medical Board of California. But what about cases that are less clear-cut? How many pre-existing children are too many for a doctor to approve of further assisted reproduction? Does it matter whether the mother seeking artificial insemination is married or single? What about if the couple looking to conceive is homosexual?
Obstetrician-gynecologists are the physicians closest to the nexus of these questions, and Pritzker School of Medicine student Ryan Lawrence and Farr Curlin, associate professor of medicine, decided to take the temperature of the field on these issues. In a paper published this month in Obstetrics & Gynecology, Lawrence and his colleagues report on the results of a survey filled out by more than 1,000 ob-gyns. The doctors were asked whether they morally or ethically object to commonly-used reproductive technologies and given seven scenarios to test whether they would discourage or refuse to offer those methods to particular women:
- the patient is not married to their sexual partner
- the patient will raise the child or children as a single parent
- the patient’s partner is female
- the patient is HIV positive
- the patient is 56 years old and postmenopausal
- the patient already has five biological children
- the patient has a 25 percent risk of dying from a heart condition during pregnancy
As you might expect, the survey results showed widespread acceptance of assisted reproduction technologies, with less than 5 percent of ob-gyns objecting to IVF or artificial insemination. Slightly more objections were found when the procedures were conducted with donor sperm or eggs, rather than sperm or eggs taken from the intended parents. Physicians who self-identified as strongly religious were more likely to balk at the use of donor cells, which the authors speculated may have to do with Roman Catholic beliefs against separating sexual intercourse from procreation and Jewish or Muslim concerns over lineage and legitimacy.
A culture shift was also seen in the more controversial scenarios. The vast majority of ob-gyns were uncomfortable with offering assisted reproduction to older women, HIV-positive women, or women with a high risk of dying during pregnancy. Single-parent, homosexual, or out-of-wedlock situations were less likely to raise objections: only about 15 percent said they would discourage such a patient, and around 10 percent said they would refuse to help.
But those differences were heightened for religious vs. non-religious physicians, with the former group as much as four times more likely to object to unmarried, single or lesbian women. Perhaps more surprisingly, male physicians, independent of religion, were also more conservative in their opinions, 2-3 times more likely to discourage patients with non-traditional family arrangements.
Such patients can take comfort in the fact that they have a choice of ob-gyn doctors – at most, only about a quarter of men or religious physicians objected to single-parent, unmarried, or lesbian households, leaving a majority of doctors without such qualms. But even in cases where a majority of ob-gyns objected, such as elderly or health-risk patients, resistance topped out around 90 percent, suggesting that even women who most doctors agree should not be assisted in reproduction can find a willing physician with enough research. With only ethical guidelines offered by the American Society for Reproductive Medicine to set the agenda, there’s little to legally stop questionable cases other than the disapproval of the field. That’s good news for tabloids looking for the next Octomom, but maybe not so much for assisted reproductive specialists who want more miracles than scandals.
Lawrence RE, Rasinski KA, Yoon JD, & Curlin FA (2010). Obstetrician-gynecologists’ beliefs about assisted reproductive technologies. Obstetrics and gynecology, 116 (1), 127-35 PMID: 20567178