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Posted on April 13, 2020 at 10:12 AM

In response to the global
Covid-19 pandemic, the American Society for Reproductive Medicine (ASRM)
created a specific task force to address infertility treatments, which were
only indirectly mentioned in other Covid-19 guidelines. Their guidelines
generated some controversy, as evidenced by a change.org
petition
that as of this writing, has over 13,300 signatures opposing ASRM’s
recommendations
to “[s]uspend initiation of new treatment cycles,” “[s]trongly
consider cancellation of all embryo transfers,” and “[s]uspend elective
surgeries and non-urgent diagnostic procedures.” More information on this
controversy, including patient narratives can be found here.
In this short piece, I want to respond to some of the claims in this petition and
ultimately support the ASRM’s decision.

            One concern with the guidelines is the language of
“elective” to describe infertility treatments. As the updated ASRM Covid-19
guidelines clarify, “[t]he use of the words ‘elective surgery’ generally refers
to surgery that can be delayed for a period of time without undue risk to the
patient.” A visceral reaction to the language of “elective” is understandable
because reproductive medicine is sometimes labeled as “elective” as a way of
dismissing it as not “real” or necessary medicine. In debates on abortion, the
label “elective” is typically not used as a medical term to indicate the
urgency of a procedure, but rather as a moral
term
about the ethical permissibility of the procedure. Similarly, in
conversations about infertility treatments, particularly regarding insurance
coverage for infertility treatments, the language “elective” is often used morally,
not medically, to convey that such treatments are low or lowest priority. On
the topic of insurance coverage, it is worth pointing out that, unlike many
other medical treatments, infertility treatments are frequently not covered by
insurance, so delaying treatment may have financial consequences for patients. It
is important to distinguish between the medical and the lay (i.e. moral) ways
of using the term “elective.”

            Even if one is using the medical definition of “elective,”
one could still object to classifying infertility treatments as elective. Some
cases, such as cancer patients about to undergo potentially sterilizing yet
life-saving treatments, are clearly time-sensitive and cannot be delayed, which
the ASRM recognizes. Other cases, however, are not as time-sensitive, such as a
heterosexual couple in their 20s with male factor infertility. Medical
guidelines about whether a procedure is elective are generally based on physiological
harms, like premature death and disability. What is often excluded, or at least
minimized, are the psychological harms. The diagnosis of infertility can be
psychologically distressing for many and asking people to delay treatment may
be further psychologically damaging. Yet, many other patients are in the same
situation; for instance, individuals diagnosed with a condition that requires
an organ transplantation may also have been devastated by their diagnosis and being
asked to wait longer can exacerbate their distress. While guidelines used to
determine whether a procedure is elective may be flawed for not explicitly
incorporating psychological harms, the fact that psychological harms are
uniformly ignored shows that infertility treatments are not being treated
differently than other medical conditions.

            Another objection to the ASRM guidelines is that they are
discriminatory toward individuals with infertility and LGBTQ individuals because
they are being denied treatment whereas people who can conceive via
heterosexual intercourse are not being told to avoid procreation nor are they
being prohibited from procreating. This objection overlooks an important
distinction between negative rights (the right from something) and
positive rights (the right to something). In medicine, negative rights
are almost universal – people can, for example, refuse lifesaving treatment. The
notable exception is dangerous and infectious diseases like Covid-19 where
people may be quarantined or isolated against their wishes. But even during a
pandemic, people maintain those negative rights that are not related to the
safety of others. Consequently, people have a negative right to make decisions
about their reproduction without interference from others, which includes
reproducing via heterosexual intercourse. Positive rights, in contrast, are
limited in medicine. For example, a patient may ask for a specific type of
medication or to be the first scheduled surgery of the day, but healthcare
professionals are not ethically obligated to fulfill all requests because they
have to adhere to professional standards and there may be other considerations
they need to take into account. Covid-19 is one such consideration. Given the
severity of this pandemic, it is justifiable for healthcare professionals to
prioritize public health over some of the needs of their patients. Patient
autonomy is not absolute and there are times when other bioethics principles,
in this case justice, should prevail.  It
is regrettable that this balancing act will disproportionately affect
individuals with infertility and LGBTQ individuals as well as many other
vulnerable individuals whose medical conditions make them more dependent upon
care from others. The response to this should not be to try to “level the
playing field” by not allowing anyone to reproduce during a pandemic (how would
we even enforce this?), but rather to strive to minimize the exacerbation of
health inequalities during a pandemic.

            In normal circumstances, healthcare professionals
(rightly) prioritize the needs of their patients. However, in the face of a
global pandemic, we are confronted with difficult decisions about whose needs
to prioritize, not just in reproductive medicine, but in all of medicine. The
ASRM guidelines are a solid place to start when addressing treatments for
patients with infertility.

 

 

 

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