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My ethics, my practice

A dose of ethical dilemmas

by Suzanne Ross

In a 1990 copy of the journal Stanford a doctor supplied a dilemma for readers subtitled: You can help them have a baby, but would they be fit parents?

In summary, the facts of the case study were:

• A couple, George and Rose, have been referred to your IVF clinic.
• George has low sperm count, Rose has a long history of endometriosis with resultant chronic pain and fertility problems.
• Many 'treatments' have been attempted and from a medical point of view you consider George and Rose to be very good candidates for in vitro fertilisation.
• From a psycho-social perspective, however, as potential parents you have severe concerns.
• Rose has had many episodes of severe depression with a long history of medication an extensive psychiatric therapy.
• The marriage appears 'stressed' and they appear far from a loving couple.
• The medication involved in the IVF process may cause mood swings.
• You discuss the effects of medication with Rose but she is determined to have a child.

What do you do?

As usual in ethical dialogue, readers responded in a variety of ways. One response challenges us to ponder the "What if ... ?" questions and to think about the facts and assumptions of the case. He writes, “The depression and absent love may be caused by nine unsuccessful years of infertility.” What responsibilities do we have to gather more information and clearly separate facts from assumptions?

Another response brings in the ethics of "Does the means justify the end?" and what is the actual meaning of the outcome; they write, “The baby might well replace the psychiatrist in her life.” Is this desirable or not?

Two responses relate to presumed outcomes, one said: “Turn them down! There is nothing to suggest this child will make Rose happier and plenty to suggest a living hell for that child.” In contrast another wrote, “I've known people from terrible situations who grow up to be gems.” And of course there are all those parents whose psycho-social profile is perfect who have terrible children! What right do we have to predetermine an outcome when in the course of one's life there is more to influence one's development than the psycho-social profile of one's parents.

Another respondent argued that “Rose needs support, not judgement, I would go ahead and request the condition that she continues psychiatric care.” Yet another said that he not go ahead with the program: he didn't want to be responsible for her ending up in a mental institution. So the question is as to what rights do we have to control the lives of others in order to protect ourselves from guilt?

We are also alerted to discrimination and the ethics of 'equal playing fields' by one of the two clearly identified doctors who responded to the dilemma. He writes that if there had not been fertility problems, then “this couple would most likely have children, no matter what their psycho-social profile.” He also suggests other aspects of the ethical landscape, eg. the importance of transparency and the duty of full explanation of options, “the infertility roller-coaster would exacerbate mood swings.” He further suggests that if the couple went ahead then the doctor had a duty to alert them to the success rate an the possible consequences of further attempts.

The second identified doctor (and who actually posed the dilemma) felt that the case raised the question of “How much responsibility, if any, physicians have in deciding who is fit to be a parent and who is not.” In the actual case he did continue with the IVF program but only after thorough counselling and evaluation.

Rose and George were fully alerted to the process and possible outcomes. He asked Rose's permission to contact her psychiatrist. This of course brings in professional codes and protocol regarding confidentiality and the respect of human rights. He found that whilst very depressed, Rose was not psychotic, suicidal or violent. Rose assured her doctor that if she felt things were not going well that she would seek assistance immediately. The first IVF attempt resulted in three out of four eggs being fertilised but no resultant pregnancy. With all of the counselling and added experience, the couple decided themselves without doctor intervention to not try again.

Let's look at another dilemma, again regarding pregnancy, but in this case, abortion. There are obvious ethical debates and concerns about abortion in general, but it is not the focus for this particular dilemma – perhaps another time!

How high is just right?

Imagine you are presented with a request for abortion. The presenting couple were born with dwarfism but scans have revealed their child to be of 'usual' height. The couple wish to have a termination because of this. Both parents argue that for them this child, which would usually be thought of as normal to others, would be abnormal. The couple's friends, family, and community considers the couple to be normal.

What do you do?

Previously we posed the question, who has the right to decide on 'fitness' to be a parent, in this scenario the question is who to who is allowed to define normality and a right to life based on this definition. Is your answer any different if the request came from:

• Brown-eyed parents about a blue-eyed child?
• 'Healthy' parents about a brain damaged child?
• Deaf or blind parents about a hearing or seeing child?
• A couple pregnant with a Downes-Syndrome child?
• Non-haemophiliac parents about a haemophiliac child?

What are the issues and what would you do?

A third and final ethical dilemma to consider

A spoonful of sugar helps the medicine go down

A highly competitive pharmaceutical company has instructed its sales people to conduct research into the spending habits of medical practitioners. In particular they have been directed to find out which charities, funds and benefits the Doctors support. As an incentive for the Doctors' to buy the company's latest line in medication the pharmaceutical company pledges to give 5% of every sale to the Doctors' favoured charities.

You have been a lifelong supporter for “Aid to Life” a notable public benevolent society and have helped organise many events to raise funds. The salesperson for the drug company has done his research well. He says that his company supports “Aid to Life” and tells you that 5% of any sale that he makes through you will be given to “Aid to Life”. You know the particular drug that he's offering is very effective, more so than your usual brand, however it has been well documented that there are side effects of slight hand-eye coordination problems.

What do you do?

• Do you decide to promote this particular drug, after all it would seem that a greater benefit is achieved for a wider number of people through the donations given to the charity than the slight discomfort felt by those relative few who take the medication?
• What if a close relative of yours needed that kind of medication, would you prescribe them this new drug, even though they would suffer hand-eye coordination problems?
• Would you take such a drug? Is it a personal sacrifice that you would make knowing that your deserving charity and those who it serves would benefit?
• Supposing that you wouldn't prescribe the drug, would it make a difference if 10, 15 or even 20% of the profits went to your charity?
• Is it fair to offer a patient the possibility of hand-eye coordination problems just so that your favoured charity can benefit?
• How serious would the side effects have to be before you wouldn't prescribe the drug, irrespective of the donation to the charity? Do you have 'zero tolerance' for prescribing drugs that have well documented side effects?

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