There are few ethical issues Ethical issues Clusters of topics that fall within the domain of bioethics, the field of study concerned with value questions that arise in biomedicine and health care delivery. Healthcare System in medicine that are more challenging than those based around reproductive issues. Personal opinions can be very strong, especially when people have differing values based on strongly held personal, religious, and/or cultural beliefs. This page will attempt to review several important ethical issues Ethical issues Clusters of topics that fall within the domain of bioethics, the field of study concerned with value questions that arise in biomedicine and health care delivery. Healthcare System surrounding reproduction and discuss the different ethical principles involved in these issues. The primary principles of medical ethics Ethics Medical ethics are a set of moral values that guide the decision-making of health care professionals in their daily practice. A sense of ethical responsibility has accompanied the profession of medicine since antiquity, and the Hippocratic oath was the 1st document to codify its core ethical principles. Medical Ethics: Basic Principles include nonmaleficence Nonmaleficence Not acting with the intention to do harm. Medical Ethics: Basic Principles, beneficence Beneficence The state or quality of being kind, charitable, or beneficial. The ethical principle of beneficence requires producing net benefit over harm. Medical Ethics: Basic Principles, autonomy Autonomy Respect for the patient’s right to self-rule. Medical Ethics: Basic Principles, and justice Justice An interactive process whereby members of a community are concerned for the equality and rights of all. Research Ethics.
Last updated: Nov 17, 2023
Although others do exist, there are 4 major principles primarily referenced in medical ethics Ethics Medical ethics are a set of moral values that guide the decision-making of health care professionals in their daily practice. A sense of ethical responsibility has accompanied the profession of medicine since antiquity, and the Hippocratic oath was the 1st document to codify its core ethical principles. Medical Ethics: Basic Principles:
In general, medical ethical dilemmas Dilemmas A clinical situation in which 2 ethical principles are at odds, and a course of action must be taken in transgression of 1 of the 2. Medical Ethics: Basic Principles are situations in which opposing arguments can be made using the 4 main principles of medical ethics Ethics Medical ethics are a set of moral values that guide the decision-making of health care professionals in their daily practice. A sense of ethical responsibility has accompanied the profession of medicine since antiquity, and the Hippocratic oath was the 1st document to codify its core ethical principles. Medical Ethics: Basic Principles.
Example: Jehovah’s Witnesses will often refuse blood transfusions Blood transfusions The introduction of whole blood or blood component directly into the bloodstream. Transfusion Products because they have a religious objection to them.
Autonomy Autonomy Respect for the patient’s right to self-rule. Medical Ethics: Basic Principles is important for both clinicians and patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship:
Contraception refers to measures a person or couple takes to prevent pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care. There are multiple different types of contraception available, including:
Oral contraceptives
Image: “Pilule contraceptive” by Ceridwen. License: CC BY-SA 2.0A 16-year-old female comes to the clinic alone requesting contraception. She is sexually active with one current partner and has been using condoms Condoms A sheath that is worn over the penis during sexual behavior in order to prevent pregnancy or spread of sexually transmitted disease. Nonhormonal Contraception, but would like something more reliable to prevent pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care. She has had one other partner, who she was last with 6 months ago. She has no medical problems and takes no medications. Her parents do not know that she is sexually active, and she does not want them to know that she is using contraception. How should you proceed?
Discussion
This patient has a right to make her own reproductive choices, which includes the decision to take hormonal contraception. She does not require a pelvic exam or (in most states) need parental consent. If you are not willing to prescribe her contraception or your employer does not allow it for religious or cultural reasons, you should refer her (without judgment Judgment The process of discovering or asserting an objective or intrinsic relation between two objects or concepts; a faculty or power that enables a person to make judgments; the process of bringing to light and asserting the implicit meaning of a concept; a critical evaluation of a person or situation. Psychiatric Assessment) to a clinician Clinician A physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients. Clinician–Patient Relationship who will. You should also discuss safe sex Sex The totality of characteristics of reproductive structure, functions, phenotype, and genotype, differentiating the male from the female organism. Gender Dysphoria practices with her, including recommending the continued use of condoms Condoms A sheath that is worn over the penis during sexual behavior in order to prevent pregnancy or spread of sexually transmitted disease. Nonhormonal Contraception to prevent STIs STIs Sexually transmitted infections (STIs) or sexually transmitted diseases (STDs) are infections that spread either by vaginal intercourse, anal sex, or oral sex. Symptoms and signs may include vaginal discharge, penile discharge, dysuria, skin lesions (e.g., warts, ulcers) on or around the genitals, and pelvic pain. Some infections can lead to infertility and chronic debilitating disease. Sexually Transmitted Infections (STIs). Finally, she should be offered screening Screening Preoperative Care for gonorrhea Gonorrhea Gonorrhea is a sexually transmitted infection (STI) caused by the gram-negative bacteria Neisseria gonorrhoeae (N. gonorrhoeae). Gonorrhea may be asymptomatic but commonly manifests as cervicitis or urethritis with less common presentations such as proctitis, conjunctivitis, or pharyngitis. Gonorrhea and chlamydia Chlamydia Chlamydiae are obligate intracellular gram-negative bacteria. They lack a peptidoglycan layer and are best visualized using Giemsa stain. The family of Chlamydiaceae comprises 3 pathogens that can infect humans: Chlamydia trachomatis, Chlamydia psittaci, and Chlamydia pneumoniae. Chlamydia if this hasn’t been done yet, which is recommended as annual screening Screening Preoperative Care for sexually active people < 25.
A surgical procedure rendering the individual incapable of reproduction. In women, this is typically via occlusion or removal of the fallopian tube Fallopian Tube A pair of highly specialized canals extending from the uterus to its corresponding ovary. They provide the means for ovum transport from the ovaries and they are the site of the ovum’s final maturation and fertilization. The fallopian tube consists of an interstitium, an isthmus, an ampulla, an infundibulum, and fimbriae. Its wall consists of three layers: serous, muscular, and an internal mucosal layer lined with both ciliated and secretory cells. Uterus, Cervix, and Fallopian Tubes: Anatomy (or hysterectomy for other indications); in men, sterilization is via vasectomy Vasectomy Surgical removal of the ductus deferens, or a portion of it. It is done in association with prostatectomy, or to induce infertility. Nonhormonal Contraception (occlusion of the vas deferens Vas Deferens The excretory duct of the testes that carries spermatozoa. It rises from the scrotum and joins the seminal vesicles to form the ejaculatory duct. Testicles: Anatomy).
A 23-year-old G4P3013 presents to the clinic requesting a tubal ligation Tubal Ligation Nonhormonal Contraception. She is married and has 3 children under the age of 4 with her husband. She has also had one elective abortion Abortion Expulsion of the product of fertilization before completing the term of gestation and without deliberate interference. Spontaneous Abortion while in high school. She has no medical problems and is currently using oral contraceptive Oral contraceptive Compounds, usually hormonal, taken orally in order to block ovulation and prevent the occurrence of pregnancy. The hormones are generally estrogen or progesterone or both. Benign Liver Tumors pills (OCPs) for contraception. She reports getting severe migraine Migraine Migraine headache is a primary headache disorder and is among the most prevalent disorders in the world. Migraine is characterized by episodic, moderate to severe headaches that may be associated with increased sensitivity to light and sound, as well as nausea and/or vomiting. Migraine Headache headaches (with aura Aura Reversible neurological phenomena that often precede or coincide with headache onset. Migraine Headache) while taking the OCPs and wants to get off hormones Hormones Hormones are messenger molecules that are synthesized in one part of the body and move through the bloodstream to exert specific regulatory effects on another part of the body. Hormones play critical roles in coordinating cellular activities throughout the body in response to the constant changes in both the internal and external environments. Hormones: Overview and Types. She states that she and her husband “are totally done” having children—she reports feeling overwhelmed caring for 3 young children, and desperately wants to avoid having more children. How do you approach the visit?
Discussion
This young mother is reporting emotional distress at the thought of another pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care. In this case, it is important to start by determining whether the patient is even aware of other contraceptive options. Because she gets migraines with aura Aura Reversible neurological phenomena that often precede or coincide with headache onset. Migraine Headache, combined hormonal contraception is contraindicated for her, so regardless of your final decision regarding sterilization, she should be switched from her current OCPs.
Regarding her request for sterilization, she should be thoroughly counseled on the permanent nature of the procedure and on the high risk of regret in young women. Even if she feels very sure now, it is important for her to recognize that as her children get older, her feelings may change.
Many experts would likely recommend strongly encouraging her to try an intrauterine device (IUD) before jumping straight to sterilization. Generally speaking, an IUD would also have lower medical risks than sterilization, and it eliminates the risk of regret.
If, however, the patient is adamant and persistent in her request for sterilization (whether or not she agrees to try an alternative option first), it would be reasonable to offer this patient a sterilization procedure based on the ethical principle of respecting patient autonomy Autonomy Respect for the patient’s right to self-rule. Medical Ethics: Basic Principles. Still, some clinicians may feel uncomfortable with her young age, and, knowing the high risk of regret, decline her request based on the ethical principle of nonmaleficence Nonmaleficence Not acting with the intention to do harm. Medical Ethics: Basic Principles (do no harm). If her request is denied, she should be offered alternative safe contraception and/or referred to another provider. Either way, excellent communication Communication The exchange or transmission of ideas, attitudes, or beliefs between individuals or groups. Decision-making Capacity and Legal Competence and demonstrating empathy Empathy An individual’s objective and insightful awareness of the feelings and behavior of another person. It should be distinguished from sympathy, which is usually nonobjective and noncritical. It includes caring, which is the demonstration of an awareness of and a concern for the good of others. Psychotherapy are key in fostering a therapeutic physician–patient relationship.
Elective abortion Abortion Expulsion of the product of fertilization before completing the term of gestation and without deliberate interference. Spontaneous Abortion is the intentional termination of pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care by medical (e.g., with misoprostol Misoprostol A synthetic analog of natural prostaglandin e1. It produces a dose-related inhibition of gastric acid and pepsin secretion, and enhances mucosal resistance to injury. It is an effective anti-ulcer agent and also has oxytocic properties. Eicosanoids) or mechanical (e.g., with aspiration or curettage Curettage A scraping, usually of the interior of a cavity or tract, for removal of new growth or other abnormal tissue, or to obtain material for tissue diagnosis. It is performed with a curet (curette), a spoon-shaped instrument designed for that purpose. Benign Bone Tumors) means.
Therapeutic abortion Abortion Expulsion of the product of fertilization before completing the term of gestation and without deliberate interference. Spontaneous Abortion is the termination of pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care as a therapeutic measure when the life of the mother is in danger.
Note:
Protest in favor of the legalization of abortion in São Paulo, Brazil
Image: “Ato em São Paulo pede a legalização do aborto” by Rovena Rosa/Agência Brasil. License: CC BY 3.0Autonomy Autonomy Respect for the patient’s right to self-rule. Medical Ethics: Basic Principles of the pregnant person:
Nonmaleficence Nonmaleficence Not acting with the intention to do harm. Medical Ethics: Basic Principles:
Note that depenalization is a public health measure seeking to stop unsafe clandestine practices.
The major argument in opposition to abortion Abortion Expulsion of the product of fertilization before completing the term of gestation and without deliberate interference. Spontaneous Abortion is that the embryo Embryo The entity of a developing mammal, generally from the cleavage of a zygote to the end of embryonic differentiation of basic structures. For the human embryo, this represents the first two months of intrauterine development preceding the stages of the fetus. Fertilization and First Week/fetus has a right to life, regardless of gestational age Gestational age The age of the conceptus, beginning from the time of fertilization. In clinical obstetrics, the gestational age is often estimated as the time from the last day of the last menstruation which is about 2 weeks before ovulation and fertilization. Pregnancy: Diagnosis, Physiology, and Care.
A 40-year-old G1P0 at 19 weeks of gestational age Gestational age The age of the conceptus, beginning from the time of fertilization. In clinical obstetrics, the gestational age is often estimated as the time from the last day of the last menstruation which is about 2 weeks before ovulation and fertilization. Pregnancy: Diagnosis, Physiology, and Care presents for her routine anatomy ultrasound. This patient struggled with infertility Infertility Infertility is the inability to conceive in the context of regular intercourse. The most common causes of infertility in women are related to ovulatory dysfunction or tubal obstruction, whereas, in men, abnormal sperm is a common cause. Infertility for years, and desperately wants this child. At her anatomy scan, she learns that her child has anencephaly Anencephaly A malformation of the nervous system caused by failure of the anterior neuropore to close. Infants are born with intact spinal cords, cerebellums, and brainstems, but lack formation of neural structures above this level. The skull is only partially formed but the eyes are usually normal. This condition may be associated with folate deficiency. Affected infants are only capable of primitive (brain stem) reflexes and usually do not survive for more than two weeks. Neural Tube Defects (no cerebral hemispheres), an anomaly incompatible with life the moment the umbilical cord Umbilical cord The flexible rope-like structure that connects a developing fetus to the placenta in mammals. The cord contains blood vessels which carry oxygen and nutrients from the mother to the fetus and waste products away from the fetus. Placenta, Umbilical Cord, and Amniotic Cavity is cut. She is devastated, and wants your advice on what she should do, because she still really wants a child.
Discussion
It is important to approach these situations with empathy Empathy An individual’s objective and insightful awareness of the feelings and behavior of another person. It should be distinguished from sympathy, which is usually nonobjective and noncritical. It includes caring, which is the demonstration of an awareness of and a concern for the good of others. Psychotherapy, and recognize that your patient may have very strongly held beliefs regarding the topic of abortion Abortion Expulsion of the product of fertilization before completing the term of gestation and without deliberate interference. Spontaneous Abortion. When discussing a diagnosis that is not compatible with life, it is important to let parents have time to grieve during the conversation. When discussing what to do next, you should review her primary options: carrying the pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care to term and delivering versus terminating the pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care.
It is important to consider the woman’s desire for a child—at age 40, and after already struggling with fertility, every additional month reduces her chances of being able to conceive another child owing to natural age-related declines in fertility. It is important that she understand what her chances of conception look like (either naturally or via in vitro fertilization Fertilization To undergo fertilization, the sperm enters the uterus, travels towards the ampulla of the fallopian tube, and encounters the oocyte. The zona pellucida (the outer layer of the oocyte) deteriorates along with the zygote, which travels towards the uterus and eventually forms a blastocyst, allowing for implantation to occur. Fertilization and First Week ( IVF IVF An assisted reproductive technique that includes the direct handling and manipulation of oocytes and sperm to achieve fertilization in vitro. Infertility)) if she were to abort now rather than wait until after delivery.
For some patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship, the idea of carrying a child they know they are going to lose for an additional 20+ weeks is more than they can bear emotionally. Terminating a pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care is safer the earlier in gestation it is performed. From a purely physical, medical standpoint, terminating the pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care now is the safest option for the woman. The primary ethical principle of nonmaleficence Nonmaleficence Not acting with the intention to do harm. Medical Ethics: Basic Principles with regard to the fetus may also hold less weight in this case, since this infant would not have a life outside the womb.
For other patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship, the idea of aborting a child, even one without a chance of survival, is one that would cause more guilt and emotional distress than they can bear. In these cases, patient autonomy Autonomy Respect for the patient’s right to self-rule. Medical Ethics: Basic Principles should be respected and the pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care care continued. Plans should be made for delivery in accordance with their wishes. For example, some may want to have a religious official there to perform a ceremony (e.g., baptism) prior to cutting the umbilical cord Umbilical cord The flexible rope-like structure that connects a developing fetus to the placenta in mammals. The cord contains blood vessels which carry oxygen and nutrients from the mother to the fetus and waste products away from the fetus. Placenta, Umbilical Cord, and Amniotic Cavity. Would the woman want to have a cesarean delivery Cesarean Delivery Cesarean delivery (CD) is the operative delivery of ≥ 1 infants through a surgical incision in the maternal abdomen and uterus. Cesarean deliveries may be indicated for a number of either maternal or fetal reasons, most commonly including fetal intolerance to labor, arrest of labor, a history of prior uterine surgery, fetal malpresentation, and placental abnormalities. Cesarean Delivery for the baby to be born alive if there was a complication during labor?
In both cases, patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship and families should be offered mental health support and grief counseling. If in a hospital setting, offering to call a chaplain may also be helpful.
Assisted reproductive technology is the use of medical techniques and technology to bring about fertilization Fertilization To undergo fertilization, the sperm enters the uterus, travels towards the ampulla of the fallopian tube, and encounters the oocyte. The zona pellucida (the outer layer of the oocyte) deteriorates along with the zygote, which travels towards the uterus and eventually forms a blastocyst, allowing for implantation to occur. Fertilization and First Week and birth of a child, including:
Biopsy of a blastocyst for pre-implantation genetic diagnosis
Image: “trophectoderm biopsy” by Greco E, Biricik A, Cotarelo RP, Iammarone E, Rubino P, Tesarik J, Fiorentino F, Minasi MG. License: CC BY 4.0, cropped by Lecturio.
Human egg fertilized in vitro
Image: “One of the 17 oocytes at the first trial remained at the germinal vesicle” by Journal of Human Reproductive Sciences. License: CC BY 4.0Case 1: IVF IVF An assisted reproductive technique that includes the direct handling and manipulation of oocytes and sperm to achieve fertilization in vitro. Infertility with PGD for aneuploidy testing
A 34-year-old woman (G1P0010) and her husband come to the office saying they want to have children but are concerned about the risk of Down syndrome Down syndrome Down syndrome, or trisomy 21, is the most common chromosomal aberration and the most frequent genetic cause of developmental delay. Both boys and girls are affected and have characteristic craniofacial and musculoskeletal features, as well as multiple medical anomalies involving the cardiac, gastrointestinal, ocular, and auditory systems. Down syndrome (Trisomy 21), given her age. She reports she would almost certainly terminate a pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care complicated by aneuploidy. The patient was doing some research Research Critical and exhaustive investigation or experimentation, having for its aim the discovery of new facts and their correct interpretation, the revision of accepted conclusions, theories, or laws in the light of newly discovered facts, or the practical application of such new or revised conclusions, theories, or laws. Conflict of Interest online and was reading up on PGD. The couple is interested in pursuing IVF IVF An assisted reproductive technique that includes the direct handling and manipulation of oocytes and sperm to achieve fertilization in vitro. Infertility with PGD. She has a history of one prior pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care with a different partner 10 years ago that she miscarried at 8 weeks. She and her current partner are both healthy and have not yet attempted to conceive. How do you proceed?
Discussion
This patient has a history of a prior pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care and no medical reason to suspect infertility Infertility Infertility is the inability to conceive in the context of regular intercourse. The most common causes of infertility in women are related to ovulatory dysfunction or tubal obstruction, whereas, in men, abnormal sperm is a common cause. Infertility. A major ethical question surrounding the use of IVF IVF An assisted reproductive technique that includes the direct handling and manipulation of oocytes and sperm to achieve fertilization in vitro. Infertility is what to do with the embryos that are created but not used, since the majority will be discarded. Similar to the topic of abortion Abortion Expulsion of the product of fertilization before completing the term of gestation and without deliberate interference. Spontaneous Abortion, there is a question of how the rights and autonomy Autonomy Respect for the patient’s right to self-rule. Medical Ethics: Basic Principles of the couple is weighed against the rights of any embryos created. Some people (often for religious reasons) have strongly held beliefs about rights afforded to an embryo Embryo The entity of a developing mammal, generally from the cleavage of a zygote to the end of embryonic differentiation of basic structures. For the human embryo, this represents the first two months of intrauterine development preceding the stages of the fetus. Fertilization and First Week, and personal opinions on this matter can vary widely. All 4 ethical principles come into play here.
In general, medical ethics Ethics Medical ethics are a set of moral values that guide the decision-making of health care professionals in their daily practice. A sense of ethical responsibility has accompanied the profession of medicine since antiquity, and the Hippocratic oath was the 1st document to codify its core ethical principles. Medical Ethics: Basic Principles principles primarily favor the living couple rather than the embryos. IVF IVF An assisted reproductive technique that includes the direct handling and manipulation of oocytes and sperm to achieve fertilization in vitro. Infertility is widely accepted as an ethically sound medical treatment option for couples with infertility Infertility Infertility is the inability to conceive in the context of regular intercourse. The most common causes of infertility in women are related to ovulatory dysfunction or tubal obstruction, whereas, in men, abnormal sperm is a common cause. Infertility seeking a biologic family based on the principles of beneficence Beneficence The state or quality of being kind, charitable, or beneficial. The ethical principle of beneficence requires producing net benefit over harm. Medical Ethics: Basic Principles and autonomy Autonomy Respect for the patient’s right to self-rule. Medical Ethics: Basic Principles. Although the case may be weaker for patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship without infertility Infertility Infertility is the inability to conceive in the context of regular intercourse. The most common causes of infertility in women are related to ovulatory dysfunction or tubal obstruction, whereas, in men, abnormal sperm is a common cause. Infertility who request IVF IVF An assisted reproductive technique that includes the direct handling and manipulation of oocytes and sperm to achieve fertilization in vitro. Infertility, it is still widely accepted and done based on principles of autonomy Autonomy Respect for the patient’s right to self-rule. Medical Ethics: Basic Principles.
The other major ethical question here is surrounding the use of PGD to avoid aneuploidy. Currently, PGD for aneuploidy testing is almost always recommended to couples using IVF IVF An assisted reproductive technique that includes the direct handling and manipulation of oocytes and sperm to achieve fertilization in vitro. Infertility starting after age 37, given the increasing risk of aneuploidy with age.
The use of PGD raises ethical questions because it requires a judgment Judgment The process of discovering or asserting an objective or intrinsic relation between two objects or concepts; a faculty or power that enables a person to make judgments; the process of bringing to light and asserting the implicit meaning of a concept; a critical evaluation of a person or situation. Psychiatric Assessment call on the part of clinicians (and patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship) to determine “how bad is bad enough” when considering what types of conditions to avoid. When multiple embryos are created but only a few will become children, is it reasonable to choose the “healthiest” embryos, which have the highest chance of successful pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care and a healthy life?
There is general agreement that life-limiting conditions (such as Tay-Sachs disease Tay-Sachs disease Tay-Sachs disease is an autosomal recessive lysosomal storage disorder caused by genetic mutations in the hexosaminidase A (HEXA) gene, leading to progressive neurodegeneration. Classic symptoms in infants include rapid degeneration of cognitive and neuromuscular abilities, progressive blindness, and a macular cherry-red spot on physical examination. Tay-Sachs Disease or trisomy Trisomy The possession of a third chromosome of any one type in an otherwise diploid cell. Types of Mutations 13) are reasonably excluded for reimplantation because these children (and their parents) would have significantly increased physical (and emotional) pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways and suffering; avoiding this outcome is a reasonable choice based on the principle of nonmaleficence Nonmaleficence Not acting with the intention to do harm. Medical Ethics: Basic Principles. Trisomy 21 Trisomy 21 Down syndrome, or trisomy 21, is the most common chromosomal aberration and the most frequent genetic cause of developmental delay. Both boys and girls are affected and have characteristic craniofacial and musculoskeletal features, as well as multiple medical anomalies involving the cardiac, gastrointestinal, ocular, and auditory systems. Down syndrome (Trisomy 21) is also a common reason for pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care termination, and if pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care termination would be planned, using PGD to avoid that outcome also is reasonable.
As with other issues in reproductive medicine, a physician needs to be mindful of their own personal beliefs and biases and recognize that a patient may have different beliefs. Physicians Physicians Individuals licensed to practice medicine. Clinician–Patient Relationship must respect a patient’s autonomy Autonomy Respect for the patient’s right to self-rule. Medical Ethics: Basic Principles, even if their beliefs differ, and refer the patient to appropriate care providers according to the laws in their area.
In this case, the patient should be referred to a fertility specialist. Based on scientific evidence and current practice guidelines, IVF IVF An assisted reproductive technique that includes the direct handling and manipulation of oocytes and sperm to achieve fertilization in vitro. Infertility with PGD for aneuploidy testing is an ethically reasonable option for this couple.
Case 2: PGD for sex Sex The totality of characteristics of reproductive structure, functions, phenotype, and genotype, differentiating the male from the female organism. Gender Dysphoria selection Selection Lymphocyte activation by a specific antigen thus triggering clonal expansion of lymphocytes already capable of mounting an immune response to the antigen. B cells: Types and Functions
A 29-year-old woman (G2P2) presents to the clinic with her husband. They already have 2 girls and really want a boy but know that they do not want more than 3 children. They are interested in IVF IVF An assisted reproductive technique that includes the direct handling and manipulation of oocytes and sperm to achieve fertilization in vitro. Infertility with PGD because they want to select a male embryo Embryo The entity of a developing mammal, generally from the cleavage of a zygote to the end of embryonic differentiation of basic structures. For the human embryo, this represents the first two months of intrauterine development preceding the stages of the fetus. Fertilization and First Week. How do you proceed?
Discussion
The use of PGD solely for the purpose of sex Sex The totality of characteristics of reproductive structure, functions, phenotype, and genotype, differentiating the male from the female organism. Gender Dysphoria selection Selection Lymphocyte activation by a specific antigen thus triggering clonal expansion of lymphocytes already capable of mounting an immune response to the antigen. B cells: Types and Functions is controversial. Is preimplantation sex Sex The totality of characteristics of reproductive structure, functions, phenotype, and genotype, differentiating the male from the female organism. Gender Dysphoria selection Selection Lymphocyte activation by a specific antigen thus triggering clonal expansion of lymphocytes already capable of mounting an immune response to the antigen. B cells: Types and Functions considered gender Gender Gender Dysphoria bias Bias Epidemiological studies are designed to evaluate a hypothesized relationship between an exposure and an outcome; however, the existence and/or magnitude of these relationships may be erroneously affected by the design and execution of the study itself or by conscious or unconscious errors perpetrated by the investigators or the subjects. These systematic errors are called biases. Types of Biases? Many would consider having a baby of the nondesired gender Gender Gender Dysphoria not “bad enough” to justify IVF IVF An assisted reproductive technique that includes the direct handling and manipulation of oocytes and sperm to achieve fertilization in vitro. Infertility and PGD, while others feel that it is reasonable and will offer the procedure based on the principle of patient autonomy Autonomy Respect for the patient’s right to self-rule. Medical Ethics: Basic Principles. There is no clearly right or wrong answer here, other than that infertility Infertility Infertility is the inability to conceive in the context of regular intercourse. The most common causes of infertility in women are related to ovulatory dysfunction or tubal obstruction, whereas, in men, abnormal sperm is a common cause. Infertility practices should have policies regarding this subject and apply the policy fairly to all patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship.
Note that in some cases, sex Sex The totality of characteristics of reproductive structure, functions, phenotype, and genotype, differentiating the male from the female organism. Gender Dysphoria selection Selection Lymphocyte activation by a specific antigen thus triggering clonal expansion of lymphocytes already capable of mounting an immune response to the antigen. B cells: Types and Functions may be beneficial to prevent transmission of recessive X-linked X-linked Genetic diseases that are linked to gene mutations on the X chromosome in humans or the X chromosome in other species. Included here are animal models of human X-linked diseases. Common Variable Immunodeficiency (CVID) genetic diseases (e.g., hemophilia A Hemophilia A The classic hemophilia resulting from a deficiency of factor VIII. It is an inherited disorder of blood coagulation characterized by a permanent tendency to hemorrhage. Hemophilia and Duchenne muscular dystrophy Muscular Dystrophy Becker Muscular Dystrophy).
To be informed about:
Case 1
A 23-year-old woman (G1P1) underwent an emergency hysterectomy after delivery of her 1st child as a lifesaving measure to stop a severe postpartum hemorrhage Postpartum hemorrhage Postpartum hemorrhage is one of the most common and deadly obstetric complications. Since 2017, postpartum hemorrhage has been defined as blood loss greater than 1,000 mL for both cesarean and vaginal deliveries, or excessive blood loss with signs of hemodynamic instability. Postpartum Hemorrhage. She and her husband want another child and decided to ask a friend to be a surrogate for them. The couple created an embryo Embryo The entity of a developing mammal, generally from the cleavage of a zygote to the end of embryonic differentiation of basic structures. For the human embryo, this represents the first two months of intrauterine development preceding the stages of the fetus. Fertilization and First Week using IVF IVF An assisted reproductive technique that includes the direct handling and manipulation of oocytes and sperm to achieve fertilization in vitro. Infertility and the embryo Embryo The entity of a developing mammal, generally from the cleavage of a zygote to the end of embryonic differentiation of basic structures. For the human embryo, this represents the first two months of intrauterine development preceding the stages of the fetus. Fertilization and First Week was implanted in their surrogate.
Situation A: During the surrogate’s pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care, she decided she no longer wanted to be pregnant and terminated the pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care.
Situation B: During the surrogate’s pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care, she decided she wanted to keep the child as her own.
Discussion
Individual autonomy Autonomy Respect for the patient’s right to self-rule. Medical Ethics: Basic Principles is paramount when considering medical ethics Ethics Medical ethics are a set of moral values that guide the decision-making of health care professionals in their daily practice. A sense of ethical responsibility has accompanied the profession of medicine since antiquity, and the Hippocratic oath was the 1st document to codify its core ethical principles. Medical Ethics: Basic Principles. In Situation A, although this may be viewed as a significant betrayal on the part of the surrogate, the surrogate has autonomy Autonomy Respect for the patient’s right to self-rule. Medical Ethics: Basic Principles over her own body and cannot be forced to carry the pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care against her wishes, even if she originally agreed to it.
In Situation B, often these cases wind up in courts, with variable Variable Variables represent information about something that can change. The design of the measurement scales, or of the methods for obtaining information, will determine the data gathered and the characteristics of that data. As a result, a variable can be qualitative or quantitative, and may be further classified into subgroups. Types of Variables outcomes as to who ends up with parental authority Authority Medical Ethics: Basic Principles. These cases are always challenging, and the laws can vary.
Case 2
A gay couple wants to have a child, and a close female friend volunteers to be a surrogate for them. The couple is unable to afford IVF IVF An assisted reproductive technique that includes the direct handling and manipulation of oocytes and sperm to achieve fertilization in vitro. Infertility, so instead, one of the men has intercourse with the friend, and she conceives. Who are the legal parents?
Discussion
In this case, since the pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care was conceived “naturally,” the woman and man whose gametes created the embryo Embryo The entity of a developing mammal, generally from the cleavage of a zygote to the end of embryonic differentiation of basic structures. For the human embryo, this represents the first two months of intrauterine development preceding the stages of the fetus. Fertilization and First Week will usually have parental authority Authority Medical Ethics: Basic Principles at birth. It will be up to the female friend to voluntarily forfeit her parental rights and for the man’s male partner to formally adopt the child. Cases can become complicated and end up in court when disagreements arise.
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