Case Scenario

I sometimes prescribe clomiphene citrate to young, healthy, nonovulatory, infertile women when they don't have the means for treatment by a reproductive endocrinologist. Recently, a young couple came to me complaining that they had been unable to conceive and that the woman had irregular periods. I told them that I could offer only a basic work-up and possibly fertility-enhancing medication, but that they would have to seek more complex intervention elsewhere. They were satisfied with that plan, and I proceeded to confirm anovulation and send them for basic endocrine evaluation, including a sperm count. They kept their office visits and complied with my recommendations. At each visit, I outlined the plan and its limitations.

I knew from the beginning that this couple was unmarried, but over time I learned that the woman was living with another man—her husband, from whom she told me she was separated. Furthermore, she informed me that her husband was beating her. I began to get the sense that she was dependent and unstable. When I spoke with her privately, I challenged her about the issue of having a child. She told me that having a child was extremely important to her because “It would make everything better.” I told her that having a child would likely complicate her relationships and that she needed counseling. I offered to arrange a visit to a social worker.

The patient then asked, “But what about the medicine you promised me?” By this time, clomiphene treatment seemed out of the question, but I felt guilty about refusing to prescribe it. I have been taught that in reproductive matters, personal decisions are sacred, so how can I justify playing God and withholding this medication simply because I have decided that this patient's interpersonal life is a mess?

Commentary

This case scenario generates many emotions, as is evident by the uncomfortable feelings expressed by the physician who is caring for this particular couple. I believe that all health care providers would sympathize with the physician in this difficult predicament. The difficulty lies in what the physician describes as “playing God.” Above all, does he have the moral obligation to continue to treat this patient according to the initial plan? This clinical situation raises the issue of whether infertility therapy is a right or a privilege. There is a “gut feeling” that prescribing ovulation-induction medications in this scenario is not appropriate for a number of reasons that may seem obvious initially, but that require further evaluation.

Organizations like the American College of Obstetricians and Gynecologists have tried to increase awareness of this serious issue and have proposed guidelines for screening, documentation, and immediate safety plans for patients,¹ as with any other medical disease.

Domestic violence (also called intimate partner violence) is a widespread problem that affects women of all ages, races, and socioeconomic groups. Approximately 5 million adult women experience domestic violence each year in the United States.¹ Most studies show a prevalence of violence during pregnancy ranging from 4 to 8 percent, and some studies suggest that violence increases during pregnancy.^2,3 Complications associated with abuse during pregnancy include poor maternal weight gain, infection, and anemia, as well as second- and third-trimester bleeding.¹ The children raised in households of domestic violence also are affected. Child abuse has been reported to occur in 33 to 77 percent of families in which an adult is abused.⁴ These children have multiple problems secondary to the environment in which they are raised.

In this case scenario, the patient believes that having her boyfriend's child will solve her problems, and she wants to continue the ovulation induction therapy. The physician should consider the effects on the unborn child's future, as well as the future of the mother and, therefore, should withhold this therapy. Just as one would recommend medical therapy for untreated hypertension or diabetes before attempting conception, the domestic violence issue should be resolved before continuing therapy with clomiphene citrate.

If the circumstances merely involved a chaotic domestic situation, this case scenario would present a more difficult dilemma, raising the question of the extent to which a patient maintains the “sacred right to reproduce” and to which a physician is required to support that right.

Based on a number of Supreme Court decisions in the 20th century, there is strong legal support for procreative liberty. Presumably, this liberty includes a couple's freedom to take advantage of available techniques, including ovulation induction and any other technology needed to conceive.⁵ From the legal perspective, there seems to be a sense of entitlement—that a couple has the right to found a family, and with that right may come an obligation to treat. However, from a moral standpoint, which is generally more narrow in scope than the legal perspective, we should ask if there are circumstances in which one has a moral obligation to refrain from reproducing or assisting in reproduction.

In 1994, the ethics committee of the American Society for Reproductive Medicine (ASRM) dealt with these issues and developed grounds on which parents may have a moral duty not to reproduce or on which health care professionals may have a moral duty not to assist in reproduction.⁵ The grounds for possible parents include issues of disease transmission to the offspring, unwillingness to provide prenatal care, inability to rear children, psychologic harm to offspring, and overpopulation.

Obviously, some of these issues are controversial, but these broad points take into account potential effects to the unborn child and society. Patients may have a sense that they are entitled to be provided with infertility therapy, but health care providers do not have the obligation to service an infertile couple unless a mutual agreement can be worked out within an acceptable patient-physician relationship.

In this case, the health care provider determined the ground rules appropriately at the beginning of the relationship with this patient. The physician was frank about his limitations and informed the patient of them. If the patient did not think she could get what she wanted or needed from this physician, she could immediately move on to someone else to obtain her therapy.

On the other hand, the patient was not equally forthright at the beginning of the relationship and did not give her physician all the necessary information about the current status of her situation. She also did not disclose her desire to carry her boyfriend's child while she was still married and apparently living in the same home with her husband. Having obtained this information, the physician now may feel professionally uncomfortable in this relationship and find it unacceptable to continue to care for this patient. Based on the ethical considerations of the ASRM, the caregiver has no obligation to continue treating this woman.

At some point, the question of the child's paternity may be raised. Does the caregiver have an obligation to protect the husband and child when paternity is determined? Even without knowing all of the motives of this woman in permitting a child to be fathered by a man she is not married to, one can easily appreciate the potential for legal problems concerning paternity and subsequent issues of monetary responsibility for the nonbiologic father. This issue alone may be sufficient to threaten the patient-physician relationship.

This physician could try to maintain the relationship and ease the quandary over reproductive assistance by articulating his discomfort with the situation, asking the patient how having a child would “make everything better,” and inviting her to explore alternative solutions. The ethical dilemma would then be referred back to the relationship, which might allow a better solution to evolve.