A new ethical discussion is emerging in the oncology world due to overwhelming advances in fertility preservation in all age groups. The journal article “The Ethics of Fertility Preservation for Paediatric Cancer Patients: From Offer to Rebuttable Presumption” addresses the pressing need to discuss the ethics of failing to preserve fertility as this current practice may no longer be considered ethically appropriate for populations for whom established techniques are available. The current standard practice involves merely offering the option of fertility preservation procedures to children and young adults with cancer.
Previous ethical discussions of fertility preservation have focused on the question of whether it is appropriate to perform fertility preservation procedures for a particular patient. The question at the heart of this article suggests the new discussion needs to address the question, “is failing to proceed with fertility preservation ethically justifiable? ’” (McDougall 2015). The article gives some background information to the pediatric oncology population, in addition to weighing the benefits and potential harms associated with fertility preservation procedures.
The author suggests that the benefits listed in the article justify assuming that fertility preservation procedures should be a part of a pediatric patient’s cancer treatment plan. The harms applicable to a particular child’s situation may then justify overriding that presumption on an individual basis. The discussion of fertility preservation is becoming increasingly important as the survival rates of childhood and young adult cancers improve. Because these populations are living longer, oncologists need to take the patient’s future quality of life into consideration beyond their immediate treatment of cancer.
This is where the discussion of fertility preservation should be introduced as a part of the patient’s cancer treatment. The British Fertility Society writes that “[s]ome 15% [of children treated for cancer] will have a high risk (95%) of early and irreversible gonadal failure, whereas others may have lesser extents of compromised reproductive capacity” (British 2003). Infertility is associated with decreased wellbeing, given the cultural significance of biological parenthood. Because biological parenthood is still an important goal for most survivors of young adult cancer, presenting the option of fertility preservation is important (Shover 005).
Fertility is linked to a person’s sense of identify and their lack of control over fertility can be a source of distress or frustration to some cancer survivors later in life (Crawshaw, Sloper 2010). The author claims that, “if we are to take seriously the idea that fertility choice is important to wellbeing, then health professionals, hospitals, and the state have a range of ethical obligations to create an environment in which fertility preservation is a presumed element of treatment for a significant subset of paediatric cancer patients” (McDougall 2015).
Based upon this principle, the author discusses two main benefits of fertility preservation procedures. The first benefit is to prevent or minimize a decrease in future fertility. By preventing this avoidable decrease, that child is given to the opportunity to make future reproductive choices. Failing to offer fertility preservation deprives the child of a choice that he or she would have otherwise had. The second benefit is the demonstration of concern for the child’s future fertility. Undergoing a fertility preservation procedure is no guarantee that the patient will become a parent to a baby who is genetically related to him or her.
However, the attempt to preserve the child’s fertility demonstrates the parents’ and clinicians’ concern for the child’s future reproductive choices. These significant benefits justify a presumption in favor of attempting fertility preservation, assuming that there are effective and established techniques available. The harms associated with fertility preservation fall into two categories: harms that can be avoided through appropriate institutional processes and harms that are intrinsic to the procedure for that individual child’s situation. Harms that can be avoided include delays to cancer treatment and concerns about false hope.
This issues can be addressed in many ways that still allow for fertility preservation to occur. The harms that are intrinsic to fertility preservation procedures present the strongest reasons to rebut the presumption. To achieve the best possible results, fertility preservation procedures need to occur before the cancer treatment begins. In some cases, undergoing such procedures can result in the child’s cancer treatment beginning later than it otherwise would have. For example, a delay of several weeks is a necessary part of ova harvest and freezing, which can act as a barrier to fertility preservation for female dolescent patients and their parents.
For certain types of cancer, the surgery involved in some fertility preservation procedures risks the cancer spreading. Also, if the cancer is of a type that involves a risk of ovarian metastases, re-implanting harvested tissue would risk a recurrence of the cancer. Clearly, failing to attempt to preserve fertility is justified when the process of fertility preservation itself increases the chances that the cancer will spread or recur. Nurses play a significant role in facilitating the discussion of fertility preservations with patients and their families.
A 2007 US study of 115 pediatric oncology nurses indicated that sperm conservation was discussed with patients in approximately half of the centers represented. , and that ova conservation was discussed with patients in approximately one fifth (38). Children and young adults have the right to be involved in decision-making in a way that reflects their emerging autonomy. The American Society for Reproductive Medicine states that fertility preservation procedures must fulfil the “requirements of minor assent, parental consent and net benefit” (note 4).
It is important that the emphasis on patient consent be seen in the context of a decision-making process rather than a single conversation, and a series of discussions with the patient and their families may be necessary. A patient’s “no” to fertility preservation should be the beginning rather than the end of the conversation. Exploring the patient’s or family’s reasons for refusal may open up possibilities for pursing fertility preservation in a way that is acceptable to the child or young person.
