Have a slice of controversy with a portion of ethics du jour

Somehow, this news slipped under my radar, probably because it issued when I was thrumming with hormones and crying in the middle of the office. But I was rummaging around online the other day when I came across this which reports the following:

"The Human Fertilisation and Embryology Authority (HFEA) are launching a wide public consultation into how clinics should protect the interests of children born through fertility treatment. Under new consultation Infertile couples could face routine criminal records checks before they are given treatment".

The consultation in question, snappily labeled ‘Tomorrow’s Children’ can be found here. I urge anyone living in Britain affected by fertility issues to read and respond to the questionnaire. The consultation paper focuses on three main areas:

• The kind of enquiries to be made of prospective parents – whether medical or social and which other professionals (i.e. social services agencies or the police) should be involved.
• The factors to be taken into account in the assessment – whether these should include medical, physical, psychological risks and social factors.
• Whether patients undergoing different kinds of treatment need different assessment and information – such as people using donor conception.

Suzi Leather, (the deliciously named Chair of HFEA), has said: “The law sets out the important principle that, before any treatment is given, clinics must consider the welfare of any child who may be born as a result. Our job as the sector’s regulator is to ensure that this is delivered in practice. There must be a reasonable, proportionate, fair and practical system that delivers an appropriate level of protection for children without unjustifiably hindering the treatment of people who need medical help in having a child."

Having read the consultation paper, my first point is that much of the news reportage of the issue has somewhat unfairly focused on the rather sexy angle of CRIMNAL CHECKS! FOR INFERTILE COUPLES! It should also be recognised that HFEA are talking about revisions to a Code of Practice rather than a change to the law. And at the moment, some assessment of medical, physical, psychological and social factors already takes place (or is meant to) prior to treatment. So in some ways, the consultation opens up the possibility for relaxing the current code.

However, the bottom line is that what the current consultaton throws into sharp relief is a key question: namely to what extent should infertile couples who require medical assistance to reproduce be treated differently than couples who conceive naturally?

I should start by saying that I view anything that HFEA says with a certain amount of wariness, primarily because I inherently distrust an organisation comprised of unelected representatives holding themselves out to be an ethical regulator and "fertility watchdog".

My views on the consultation proposals are this: On balance, I think that the legal requirement to take into account the welfare of any child born as a result of assisted conception should be generally be limited to questions of medical risk to the child to be born. I think that any further routine "social enquiries" involving any third party/agencies takes us into into dangerous territory, a tenuous ethical landscape where external value judgements and assumptions assume a crucial yet dubious importance. I think it's a slippery slope that has potential to give even more authority over a couple's family building choices to physicians and clinicians, who in some cases already have far too much power over the process, in my opinion.

I can fully apprecate the arguments that it would be preferable if drug addicted, child-abusing psychopaths did not become parents via IVF. Moreover I can see a thorny ethical issue in a scenario arising where a patient seeking IVF, apart from any obvious medical risk to the child, appeared to all concerned to be a wholly unsuitable candidate for parenthood. For that reason, I think there probably should be scope to make additional enquiries in exceptional cases where there is a clear and justifiable reason to do so. But even that makes me a little uncomfortable-because how do we define what is a clear reason? Who gets to decide if a certain factor is a "problem"?

Furthermore the whole issue generally makes me grapple with how we go about evaluating the welfare of the child - a child that is not yet in existence and may never come into existence. How do we fully and properly assess a future scenario that may never come to be?

What HFEA seem to recognise is that at present it can be very hard to to ascertain in all cases if there is a "problem" and if so how is that issue explored or resolved is a bit of a grey area. The consultation paper talks about using a patient questionnaire. But they also recognise that, cunningly, people with a potential problem which might preclude them from receiving treament might lie on such a questionnaire. At the moment some clinics make enquiries to GPs, but of course in many cases, a GP is really not going to be in a position to give any sort of meaningful evaluation of fitness to be a parent. I mean, I have met my GP maybe 5 times. Which leaves talking to a social worker, or the police.

The problem is that takes us from one end of the spectrum (not many checks) to the other (criminal records search, for example). Anything in the middle risk is fairly unsatisfactory, in that it risks pissing off potential patients (who frankly, are usually feeling vulnerable enough as it is) while failing to really ensure any problems are caught.

Findings on the use of the current "welfare of the child" assessment guidance indicate that patients are rarely refused treatment, suggesting that any benefit of the present system is disproportionate to the time and resource required to carry out the checks. I'm guessing that has a lot to do with the fact that most people who reach the point of seeking assisted conception have already thought long and hard about parenthood, have already undergone a certain amount of intrusive and painful interventions, have already made difficult decisions about family building.

But leaving aside all the ethical dilemmas, I have to say that on an emotive level I simply find the whole notion that infertile couples should have to contemplate the possibility of additional hurdles, such as an interview with a social worker, or a criminal record check to be repugnant, invasive, and downright creepy. I cannot even begin to imagine how upsetting and stressful it would be to sit in the waiting room, knowing that not only will your physical body be wide open for all to see, but wondering if they are going find anything else which will prevent you from receiving treatment.

It also may a knee-jerk reaction but all I can think if IVF candidates are required to routinely undergo detailed checks, then who's checking the parents who conceive naturally? The people who in some cases conceive carelessly and thoughtlessly? Or who make reproductive choices as private decisions, and subsequently parent without being subjected to any sort of assessment whatsoever? HFEA's rationale on that point seems to be that once a person requires the intervention of third parties, such as medical staff, then this does put people on a different footing, one more akin to adoption. So really, if ever there was a practice designed to further widen the gulf between the experience of the bountiful uber-fertile and the bitter isolated infertile, this is it.

I'd really, really appreciate comments on this, which may help me to finalise my opinion and articulate my views to HFEA when I come to respond to the questionnaire. I'm also very interested in what goes on in other countries- for example, is there any form of check in the States prior to commencing treatment? If so, how do you feel about that?