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Marcel J. Mélançon *, R. D. Lambert **

Philosophe, professeur chercheur en bioéthique à l’UQAC
Directeur du Groupe de recherche en génétique et éthique
du Québec (GÉNÉTHIQ), d’une part,
et Département d’Obstétrique et de Gynécologie, Université Laval, d’autre part.

“Health of ARTs babies
and the responsibility
toward the next generation”.

Un article publié dans un ouvrage sous la direction de Salim Doya, Roger Pierson et Joanne Gunby, Research Papers in Fertility and Reproductive Medecine. Proceedings of the 18th World Congress on Fertility ans Sterility (IFSS 2004) held in Montreal, 23-28 May 2004, pp. 349-352. Ansterdam : Elsevier, 1st Edition, 2004, 426 ppl. Collection : International Congress Series 1271 (2004).

Abstract

1. Introduction

2. Discussion

2.1. The principle of autonomy
2.2. The physician’s responsibility

2.3. The future child as part of the decision making

2.4. Conclusion

Acknowledgments

Abstract

Health problems have been observed more frequently in multiple and even in singleton ARTs babies than in control populations. A dilemma may arise : The respect of a couple's autonomy may conflict with the responsibility towards the next generation. The objective of this presentation is to re-evaluate the advisability of offering therapy based upon the unconditional respect of the autonomous choice of infertile individuals. The ethical framework for this re-evaluation was that of the principle of responsibility. This principle was applied to the process of decision making. This process involves (a) the couple's choice (respect of autonomy), (b) the medical opinion (the physician's responsibility) and (c) the respect of the embryo as a future child (health problems related to infertility treatment). From this re-evaluation, we conclude that the transfer of several embryos should be avoided in most of the cases, even if it is the couple's choice. © 2004 Elsevier B.V All rights reserved.

Keywords : IVF ; Health problems ; Respect of autonomy ; Physician's responsibility

1. Introduction

Health problems have been observed more frequently in children of ARTs than in control populations. Twin gestation is the most important risk factor [1] [2]. Such observation is not surprising since multiple embryo transfer results in multiple pregnancy which, in turn results in higher risks of abortion, premature birth, low birth weight, cerebral palsy, neonatal mortality, etc. [3]. In light of this new information a dilemma may arise : The respect of a couple's autonomy may conflict with the physician's responsibility towards the next generation. In other words, is it ethically acceptable to transfer several IVF embryos, knowing the risk of multiple pregnancies for the health of the babies ? The objective of this paper is to re-evaluate the advisability of offering therapy based upon the unconditional respect of the autonomous choice of infertile individuals.

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2. Discussion

The ethical framework for this re-evaluation was based upon the principle of physician's responsibility. This principle was applied to the process of decision making. This process involves (a) the couple's choice (respect of autonomy), (b) the medical opinion (the physician's responsibility) and (c) the respect of the embryo as a future child (health problems related to infertility treatment).

2.1. The principle of autonomy

Personal autonomy is central in moral philosophy, bioethics in general and clinical ethics in particular. Already present in the Greek philosophers' thought [4] [5], it became rooted in the Western world tradition. Kant [6] opposed it to heteronomy. The Belmont Report [7] made this value one of the key principles in bioethics. "The concept of autonomy in moral philosophy and bioethics recognizes the human capacity for self-determination and puts forward a principle that the autonomy of persons ought to be respected" [8]. The principle of autonomy is two-dimensional : The person who should be independent of undue pressures reducing or impairing free and informed consent [9] and the action which is a reflection of this independence for obtaining a free and informed consent. The principle of autonomy requires that the physician respect the point of view of the infertile patient. But, to become operant, the principle of autonomy must fulfill two conditions : All the information necessary to make an informed decision must be presented to the patient and undue pressure must be avoided. Thus, in agreement with the principle of autonomy, an infertile couple requiring an IVF treatment is able to make a free and informed decision regarding a treatment proposed by the physician, only (1) when the treatment itself and its consequences on the woman and the future infant are clearly described and (2) when the patient is not submitted to undue pressure.

In this respect, underestimation of the difficulties of raising multiple children, the emotional stress of infertility, the financial context, etc., may limit "…the parental capacity to make decisions about the number of embryos to be replaced..." [10]. Yet, is the respect of this free choice absolute, unlimited or unconditional, as suggested recently : "...isn't choice one of the most basic human rights ? (...) the patient's right to choose. Don't patients have the right to choose different risk levels, based on their own, private circumstances and desires ? Isn't it patronizing to assume that well educated adults are incapable of making such decisions in a personal and responsible way ?" [11].

2.2. The physician’s responsibility

The first professional responsibility of the physician, as an autonomous agent, is to promote the health of his patients and to prevent diseases, in this case infertility. He must be committed to his deontological, ethical and legal obligations toward the infertile couple and respect the infertile couple's decision, within the therapeutic contract binding both parties.

But, when scientists give proof of increasing risks associated with infertility treatment, the physician has to question himself and be cautious. His deontological code puts him under the obligation of not only promoting health, but also of preventing undesirable effects of prescribed treatments. Therefore, within the context of infertility treatment, he [351] has to take into consideration both the infertile couple's wishes and the risks for the next generation, namely the health of future children.

2.3. The future child as part of the decision making

Indeed, not to be forgotten is the fact that clinical and ethical decision making involves a third party, that is the future child and his health. The issue of the major risks incurred by the child-to-be has to be addressed, as it may limit the couple's free choice and the corresponding physician's obligation to accept their decision. In case of conflict between the couple's request and the physician's responsibility, the dilemma may be solved by considering responsibility toward next generations.

2.3.1. Responsibility toward future generations

Ethical concern for future generations is a relatively recent phenomenon in Western thought. It was best expressed by German philosopher Hans Jonas, who developed the principle of responsibility in a society in search of an ethics for the technological age [12]. This principle is based on a new ethical thought, according to which human conduct was transformed by scientific knowledge and ensuing technological progress. Humans are now endowed with hitherto unsuspected powers which must be taken into account in the entirely new decision-making process involving the future. Traditional ethics, going back to the time of ancient Greece [13], has become ineffective in modem times, since it considers human conduct in terms of short- and medium-range interpersonal and social relationships; concern for long-range action consequences is absent. Now, techno-science, while promising grand and priceless benefits to humanity, is nevertheless a source of risks potentially dramatic for future generations. Good and evil can no longer be considered within a short-term context. They transcend the time limits of our era and their consequences will take effect in a distant future. Consequently, humanity must be accountable to future generations for its actions.

This principle thus implies an ethics of cautiousness, foresight and risk prevention. Two obligations make the foundation for this future-oriented ethics: (a) Before taking any action, consider its long-term effects and (b) be sensitive to happy or unhappy fate of future generations. According to the Jonas' thought, these concerns are of particular importance in the fields of environment (nature having become vulnerable through human intervention) and of health (interventions may alter future generations).

2.4. Conclusion

In the field of infertility treatment, the application of the principle of autonomy is not unconditional and must be restricted in some cases by the principle of responsibility. The physician, therefore, in his therapeutic decision making, is not under the obligation of unconditionally respecting infertile people's autonomy. In addition, the principle of respect for future generations, including precaution toward risks to the health of children from assisted reproduction, can justify a physician's decision in favour of these children. Consequently, we firmly support ESHRE's [9] position that : (1) the transfer of several embryos should be avoided in most cases, even if it is the couple's choice, given the risks for the babies ; (2) protection of the vulnerable is the physician's responsibility.

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Acknowledgments

Funded by G6nome Qu&bec and G6norne Canada (GEDS project).