Ask the Ethicist: Eating for two?

“We’ve had many angry patients say to us, ‘This [denying obese women fertility treatments] is discriminatory’ and I say, ‘Yes, it is’ But I still won’t do it,” said Arthur Leader, co-founder of the Ottawa Fertility Centre. The facility where he works will not treat women with a Body Mass Index (a measurement of weight relative to height) of more than 35. A BMI of 30 meets the clinical definition of obese. “A patient doesn’t have the right to make a choice that’s going to be harmful to them,” he said. (excerpt from the September 20th Globe and Mail)

I’ve been hearing a lot about the Canadian Fertility and Andrology Society conference which took place in Toronto in September. Most of what I’ve heard has been anger at some of the discussions over what constitutes the accepted standards of professional practice. This particular topic has been lighting up the internet discussion boards and I thought I would like to comment on a couple of the aspects that came up a lot in discussion.

First, it might make sense to discuss Dr. Leader’s comment about discrimination. The common usage is often linked to denying someone a human right or something they are entitled to do by virtue of their race, sex, creed and several other personal identifiers or characteristics. This is wrong and not allowed. A more inclusive (and accurate) definition of discrimination includes denying someone a human right, but the difference is that there are justifiable reasons to do so. My university doesn’t accept every applicant, because they have placed academic achievement standards on potential students. Students who fall below this standard must look elsewhere for admission. Is this discrimination? Yes. Is it justifiable? Yes, even as we debate the value of high school marks as a measure of achievement or ability.

By contrast, in the pre-World War Two period, Jewish students who applied to University of Toronto or McGill could have been rejected due to quotas which limited the number of Jewish students in their institutions. Is this discriminatory? Obviously. Is it justified? No – this is discrimination in the currently dominant sense of the word. The question in debate currently is if it is justifiable to discriminate against obese women. What could make it acceptable is if the risks these women faced were unusually high to themselves and their potential offspring.

It was interesting to note that the risks of in-vitro fertilization (IVF) treatments came under attack as excessively risky to the offspring. The propensity for multiple births arising from IVF comes with serious risks, including:

1.) Twins are four times as likely as singletons to die at birth

2.) 25 per cent of twins spend at least 18 days in the intensive-care unit and 75 per cent of triplets spend 30 days or more in the ICU

3.) The risk of cerebral palsy is four times higher for twins and 17-times higher for triplets

4.) Women carrying twins are 2.6 times as likely to get pregnancy-related high-blood pressure

We must consider the risks involved for healthy patients for a certain treatment before discriminating against other patients for the “high risks” they face.

When we consider the risks of such a treatment, Dr. Leader notes that patients don’t have the right to make a self-harming choice. One hopes that this is a mis-quote of Dr. Leader, because he is categorically wrong. Competent patients have the right to make treatment choices that can lead to their own deaths if they wish, and physicians can’t interfere with that choice. At the same time, physicians can’t be compelled to participate in treatments they can justifiably discern as futile or excessively harmful to the patient. So while patients can refuse any treatment to their own detriment – even deaths – it doesn’t follow that they can receive any treatments they want despite the risks.

It will be interesting to see how this all pans out on the three major issues or risk to the patient, rights of the physician to refuse treatment (and the justifications for doing so), as well as how full provincial funding of IVF will affect public policy in this area.