- Email: [email protected]
Professional integrity, respect for autonomy, and the self-regulation of reproductive endocrinology
www.AJOG.org
Editorials
Professional integrity, respect for autonomy, and the selfregulation of reproductive endocrinology Frank A. Chervenak, MD; Laurence B. McCullough, PhD
M
ore than any other case of reproductive medicine in recent years, the California octuplets have caused a furor in the print and electronic media. As a result, there has been more heat than light shed on the ethical challenges that this case raises for reproductive endocrinologists. Minkoff and Ecker1 are a welcome exception because their editorial sheds an important light on this controversy, especially their emphasis on the crucial distinction between social judgments and professional judgments. We strongly agree with their conclusion that physicians should confine themselves to the latter. In our view, the ethical principle of respect for autonomy as prima facie2,3 and the ethical concept of professional integrity4 are invaluable for understanding how reproductive endocrinologists should respond, not only to controversies, but also more importantly to patients’ requests in everyday clinical practice. Ethical principles, such as respect for autonomy, provide guides to clinical decision-making about what ought to be done in patient care, but these principles should not be considered absolute (ie, never allowing for exceptions). In the technical language of ethics, such principles are prima facie.2,3 Respect for autonomy, for example, should guide physicians, unless there is compelling ethical justification for not doing so.5,6 Professional integrity provides such a justification. This virtue requires physicians to practice medicine, conduct research, and teach according to standards of intellectual and moral excellence. Intellectual excellence means that clinical judgment, decision-making, and action should conform to the discipline of evidence-based reasoning. Moral excellence means that physicians should make the protection and promotion of patients’ health-related interests the primary concern and motivation, keeping self-interest systematically secondary. When patients make requests that are not consistent with professional integrity, the physician should not fulfill them.6 Out of respect for patient autonomy, reproductive endocrinologists have a prima facie obligation to implement the informed decision of a patient for infertility services. Professional integrity
From the Department of Obstetrics and Gynecology, Weill Medical College of Cornell University, New York, NY (Dr Chervenak); and the Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX (Dr McCullough). Reprints: Frank A. Chervenak, MD, Department Obstetrics and Gynecology, New York Hospital/Cornell Medical Center, 525 East 68th St., J130, New York, NY 10021. [email protected]. 0002-9378/free © 2009 Published by Mosby, Inc. doi: 10.1016/j.ajog.2009.05.029
See related article, page 15
limits this obligation because this virtue requires the physician to protect the health-related interests of pregnant, fetal, and neonatal patients. In the rare instance in which a woman has a severe medical condition that evidence-based reasoning justifiably supports as a contraindication to pregnancy, her request for reproductive medical services should be denied. Similarly, if a woman requests to have more embryos transferred than recommended by the Society for Assisted Reproductive Technology/American Society for Reproductive Medicine guidelines,7 protection of the fetal patient’s and neonatal patient’s health-related interests from the documented risks of high-order multiple gestations takes precedence over her request, which should be respectfully but firmly refused. This conclusion is reinforced when the Society for Assisted Reproductive Technology/American Society for Reproductive Medicine guidelines are considered in the context of more restrictive laws in other countries about the number of embryos to be transferred. Physicians overstep their professional integrity and misuse their professional authority when they object to reproductive medicine services on grounds that lack a basis in well-founded medical reasoning. Social concerns, such as whether a woman with 6 children should become pregnant or whether a woman of modest economic means and social resources should become pregnant, are judgments that physicians in evidencebased clinical reasoning are not competent to make. Professional integrity requires that these concerns not limit a woman’s autonomy in requesting reproductive services. Integrity also requires that the physician’s personal biases in these matters not influence the informed consent process. It follows from this ethical analysis that the California octuplet case never should have happened because the number of embryos that were transferred egregiously violated professional integrity and had nothing to do with patient autonomy that is understood properly as a prima facie ethical principle. Accepted means exist to address such a case: evidence-based assessment by professional and state authorities and penalties when warranted by such assessment. These review processes should be allowed to run their course. A single, socially, very unusual case does not mean that “the time has come to transform guidelines into regulations congruent with those in other countries such as the United Kingdom.”1 Our concern is that government regulation is, by its very nature, at high risk of becoming inflexible and therefore of restricting the autonomy of women without an evidencebased justification. The current approach of self-regulation in the United States is evidence-based,7 and there is no evidence of widespread failure to adhere to professional integrity. Controversies such as the California octuplets make for compelling content for the now-familiar 24-hour cable news JULY 2009 American Journal of Obstetrics & Gynecology
3
Editorials cycle because they are a volatile mix of advanced medical technology, social attitudes, and what McLuhan and Fiore8 called “hot” personalities in the “cool” medium of television. A balanced approach to the ethical concept of professional integrity and the prima facie ethical principle of respect for women’s autonomy prevent excessive emphasis on either and best serves the health-related interests of pregnant, fetal, and neonatal f patients. REFERENCES 1. Minkoff H, Ecker J. The California octuplets and the duties of reproductive endocrinologists. Am J Obstet Gynecol 2009;201:15.e1-3. 2. Beauchamp TL, Childress JF. Principles of biomedical ethics, 6th ed. New York: Oxford University Press; 2009.
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American Journal of Obstetrics & Gynecology JULY 2009
www.AJOG.org 3. McCullough LB, Chervenak FA. Ethics in obstetrics and gynecology. New York: Oxford University Press; 1994. 4. Chervenak FA, McCullough LB. The moral foundation of medical leadership: the professional virtues of the physician as fiduciary of the patient. Am J Obstet Gynecol 2001;184:875-9. 5. McCullough LB, Chervenak FA, Coverdale JH. Argument-based ethics: a formal tool for critically appraising the normative medical ethics literature. Am J Obstet Gynecol 2004;191:1097-102. 6. Chervenak FA, McCullough LB. Justified limits on refusing interventions. Hasting Cent Rep 1991;21:12-8. 7. Practice Committee of Society for Assisted Reproductive Technology; Practice Committee of American Society for Reproductive Medicine. Guidelines on number of embryos transferred. Fertil Steril 2008; 90(suppl):S163-4. 8. McLuhan M, Fiore Q. The medium is the massage. New York: Bantam Books/Random House; 1967.
Editorials
Professional integrity, respect for autonomy, and the selfregulation of reproductive endocrinology Frank A. Chervenak, MD; Laurence B. McCullough, PhD
M
ore than any other case of reproductive medicine in recent years, the California octuplets have caused a furor in the print and electronic media. As a result, there has been more heat than light shed on the ethical challenges that this case raises for reproductive endocrinologists. Minkoff and Ecker1 are a welcome exception because their editorial sheds an important light on this controversy, especially their emphasis on the crucial distinction between social judgments and professional judgments. We strongly agree with their conclusion that physicians should confine themselves to the latter. In our view, the ethical principle of respect for autonomy as prima facie2,3 and the ethical concept of professional integrity4 are invaluable for understanding how reproductive endocrinologists should respond, not only to controversies, but also more importantly to patients’ requests in everyday clinical practice. Ethical principles, such as respect for autonomy, provide guides to clinical decision-making about what ought to be done in patient care, but these principles should not be considered absolute (ie, never allowing for exceptions). In the technical language of ethics, such principles are prima facie.2,3 Respect for autonomy, for example, should guide physicians, unless there is compelling ethical justification for not doing so.5,6 Professional integrity provides such a justification. This virtue requires physicians to practice medicine, conduct research, and teach according to standards of intellectual and moral excellence. Intellectual excellence means that clinical judgment, decision-making, and action should conform to the discipline of evidence-based reasoning. Moral excellence means that physicians should make the protection and promotion of patients’ health-related interests the primary concern and motivation, keeping self-interest systematically secondary. When patients make requests that are not consistent with professional integrity, the physician should not fulfill them.6 Out of respect for patient autonomy, reproductive endocrinologists have a prima facie obligation to implement the informed decision of a patient for infertility services. Professional integrity
From the Department of Obstetrics and Gynecology, Weill Medical College of Cornell University, New York, NY (Dr Chervenak); and the Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX (Dr McCullough). Reprints: Frank A. Chervenak, MD, Department Obstetrics and Gynecology, New York Hospital/Cornell Medical Center, 525 East 68th St., J130, New York, NY 10021. [email protected]. 0002-9378/free © 2009 Published by Mosby, Inc. doi: 10.1016/j.ajog.2009.05.029
See related article, page 15
limits this obligation because this virtue requires the physician to protect the health-related interests of pregnant, fetal, and neonatal patients. In the rare instance in which a woman has a severe medical condition that evidence-based reasoning justifiably supports as a contraindication to pregnancy, her request for reproductive medical services should be denied. Similarly, if a woman requests to have more embryos transferred than recommended by the Society for Assisted Reproductive Technology/American Society for Reproductive Medicine guidelines,7 protection of the fetal patient’s and neonatal patient’s health-related interests from the documented risks of high-order multiple gestations takes precedence over her request, which should be respectfully but firmly refused. This conclusion is reinforced when the Society for Assisted Reproductive Technology/American Society for Reproductive Medicine guidelines are considered in the context of more restrictive laws in other countries about the number of embryos to be transferred. Physicians overstep their professional integrity and misuse their professional authority when they object to reproductive medicine services on grounds that lack a basis in well-founded medical reasoning. Social concerns, such as whether a woman with 6 children should become pregnant or whether a woman of modest economic means and social resources should become pregnant, are judgments that physicians in evidencebased clinical reasoning are not competent to make. Professional integrity requires that these concerns not limit a woman’s autonomy in requesting reproductive services. Integrity also requires that the physician’s personal biases in these matters not influence the informed consent process. It follows from this ethical analysis that the California octuplet case never should have happened because the number of embryos that were transferred egregiously violated professional integrity and had nothing to do with patient autonomy that is understood properly as a prima facie ethical principle. Accepted means exist to address such a case: evidence-based assessment by professional and state authorities and penalties when warranted by such assessment. These review processes should be allowed to run their course. A single, socially, very unusual case does not mean that “the time has come to transform guidelines into regulations congruent with those in other countries such as the United Kingdom.”1 Our concern is that government regulation is, by its very nature, at high risk of becoming inflexible and therefore of restricting the autonomy of women without an evidencebased justification. The current approach of self-regulation in the United States is evidence-based,7 and there is no evidence of widespread failure to adhere to professional integrity. Controversies such as the California octuplets make for compelling content for the now-familiar 24-hour cable news JULY 2009 American Journal of Obstetrics & Gynecology
3
Editorials cycle because they are a volatile mix of advanced medical technology, social attitudes, and what McLuhan and Fiore8 called “hot” personalities in the “cool” medium of television. A balanced approach to the ethical concept of professional integrity and the prima facie ethical principle of respect for women’s autonomy prevent excessive emphasis on either and best serves the health-related interests of pregnant, fetal, and neonatal f patients. REFERENCES 1. Minkoff H, Ecker J. The California octuplets and the duties of reproductive endocrinologists. Am J Obstet Gynecol 2009;201:15.e1-3. 2. Beauchamp TL, Childress JF. Principles of biomedical ethics, 6th ed. New York: Oxford University Press; 2009.
4
American Journal of Obstetrics & Gynecology JULY 2009
www.AJOG.org 3. McCullough LB, Chervenak FA. Ethics in obstetrics and gynecology. New York: Oxford University Press; 1994. 4. Chervenak FA, McCullough LB. The moral foundation of medical leadership: the professional virtues of the physician as fiduciary of the patient. Am J Obstet Gynecol 2001;184:875-9. 5. McCullough LB, Chervenak FA, Coverdale JH. Argument-based ethics: a formal tool for critically appraising the normative medical ethics literature. Am J Obstet Gynecol 2004;191:1097-102. 6. Chervenak FA, McCullough LB. Justified limits on refusing interventions. Hasting Cent Rep 1991;21:12-8. 7. Practice Committee of Society for Assisted Reproductive Technology; Practice Committee of American Society for Reproductive Medicine. Guidelines on number of embryos transferred. Fertil Steril 2008; 90(suppl):S163-4. 8. McLuhan M, Fiore Q. The medium is the massage. New York: Bantam Books/Random House; 1967.