AMA Journal of Ethics®

Illuminating the art of medicine

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AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. October 2014, Volume 16, Number 10: 785-786.

From the Editor

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Advancing Innovation in Reproductive Care

Introduction to the October 2014 issue of Virtual Mentor on ethics in reproductive technology.

Obstetrics and gynecology involves the provision of medical and surgical care to women over their lifespan, a breadth of caregiving that sets the field apart. Perhaps more striking, though, is the sociopolitical attention women’s health has garnered in the United States. Recent legislative efforts have empowered politicians, employers, health professionals, insurers, and even the parents of adolescents to restrict women’s reproductive choices, both domestically and even internationally through prohibitions on uses for federal funds. This phenomenon has more than short-term health consequences. Our society’s intense concern with reproductive care has also hampered our ability to innovate and improve outcomes in the long term. Such efforts include “fetal personhood” legislation that threatens the legality of treatment for infertility or ectopic pregnancy, restrictions on research involving pregnant women or embryonic stem cells, and limited insurance coverage for the most efficacious forms of contraception.

Emotions can run high around childbearing, parenthood, and babies. Society, it seems, wants a voice in what happens to all “its” children, from conception forward. This voice, however, is not a unified one, but a raucous discourse of disparate views often based on fundamentally differing values and beliefs. So for leaders in biomedicine, maintaining an objective and dispassionate stance is a challenging but critical requirement for providing and improving reproductive medicine. This theme issue of Virtual Mentor addresses areas of innovation in the field of women’s health and highlights some of the ethical pitfalls we encounter in the attempt to advance reproductive care.

This month’s three ethics case commentaries address the challenges of keeping up with new guidelines and technologies. Frank A. Chervenak and Laurence B. McCullough discuss a patient’s request for an elective labor induction before 39 weeks. Marc M. Beuttler, Kara N. Goldman, and Jamie A. Grifo argue for providing ovarian reserve testing to promote informed decision making for women interested in future fertility, regardless of the anxiety that accompanies such discussions. And Harry J. Lieman and Andzrej K. Breborowicz discuss the ethical considerations related to sex selection in pregnancies conceived through in vitro fertilization (IVF).

In the state of the art and science section are discussions of two more technological advancements: Monique A. Spillman and Robert M. Sade address the rapid propagation of robotic gynecologic surgery and the ethical questions it has engendered. Stephanie J. Miller and Joseph B. Davis discuss whether, in the absence of meaningful standards for experience or certification, the disclosure of a fertility clinic’s experience with egg freezing—a procedure considered experimental until recently—will be useful for patient decision making.

Two articles discuss matters of justice. Caroline Bass and Joseph Gregorio elucidate how a lack of appropriate regulation has led to subpar treatment of egg donors. Carolyn Payne and Nicole Fanarjian review a study that sought to identify the causes of racial disparities in the use of the long-acting reversible contraception.

The remaining pieces address society’s preoccupation with pregnancy and the fetus. Kavita Shah Arora and Christina Salazar examine the logical and ethical flaws in laws that restrict abortions based on the assertion that a 20-week fetus can feel pain. Ruth Macklin gives a more general overview of legislative, judicial, and physician-led restrictions on abortion in the US, maintaining her contention that the pregnant woman alone should “have the final say” in the future of her fetus. Two articles question common obstetric practices. Stephen T. Chasen challenges the wisdom of aggressive interventions to prolong pregnancy in patients with advanced cervical dilation prior to viability of the fetus. Lauri J. Romanzi weighs in on the debate, raging in both medical literature and the lay “mommy wars,” on the medicalization of childbirth. Finally, in this month’s podcast, Sarah S. Richardson elaborates her research in maternal effects—the influences of a pregnant woman’s behavior, exposures, and physiology on her offspring’s future health and development. This set of pieces highlights the moral ramifications of the widespread entanglement of society and trends in reproductive care.

As we continue to attempt to push reproductive medicine ever forward, we must continue to balance the quest for scientific advancement with the responsibility to maintain thoughtfulness and irreproachable ethics in the provision of women’s health care.

Rashmi Kudesia, MD Fellow in reproductive endocrinology and infertility Albert Einstein College of Medicine New York, NY



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