Letter to the editor |
‘Reproductive tourism’: should locally registered fertility doctors be held accountable for channelling patients to foreign medical establishments?
National University of Singapore, 5 Lower Kent Ridge Road, 119074 Singapore
E-mail: denhenga{at}nus.edu.sg
Sir,
In many countries where the commercialization of human gametes and embryos is explicitly banned by law, the resultant effect is often severe shortages and long patient waiting lists (McMillan and Hope, 2003
; Sidebotham, 2003). This in turn has led to increasing numbers of patients going abroad to seek donated gametes and embryos that are commercially available in a foreign country, in what is commonly referred to as ‘reproductive tourism’ (Pennings, 2004). A good example is the current situation in the UK, where inadequate monetary compensation (Craft et al., 1997; Johnson, 1997), together with the threat of removal of donor anonymity (Fortescue, 2003) has led to a severe shortage of donated gametes and embryos. This in turn provides a strong impetus for many childless British couples to seek treatment abroad (Sauer, 1997, 2005).
The aim here is not to debate ethics and legislation pertaining to the commercialization of human gametes and embryos. Instead, the focus is on a more pertinent problem at hand; that is of locally registered fertility doctors having a vested interest in foreign medical establishments that deal with commercialized gametes and embryos. Obviously, if local medical professionals own a proprietary share in a foreign medical establishment, there would be a strong financial incentive to channel patients there for treatment, away from restrictive regulations at home that disallows gamete and embryo commercialization. No doubt, referrals can be done without imposition of medical fees and there could be an apparent lack of financial gain to the medical professional involved. However, this is difficult to be transparent to patients and the pertinent local health authority. In particular, it is extremely difficult to prove or disprove the vested interests of local medical professionals in foreign medical establishments, which may or may not be held through a second party (i.e. spouse or close relative). Additionally, there is also seldom any legislation to stop medical professionals from travelling abroad themselves to perform clinical procedures relating to donated gametes and embryos.
This is deplorable because a basic tenet in the ethos of medical professionals is respect for the laws and regulations governing clinical practice in their home country. Sometimes, restrictive regulations may appear outdated and unnecessary; however, these still warrant respect from medical professionals despite any personal reservations or objections that they might have. It must be remembered that these regulations in fact represent the socio-cultural values and ethical standards of their home country in which they run their clinical practice. Medical professionals should therefore embrace the ‘spirit and essence’ of the legislation, rather than just blindly follow the ‘letter of the law’.
No doubt, it may be counter-argued that medical doctors should instead abide by their professional deontology to aid treatment of patients, and do whatever is necessary in the best interest of their patient’s welfare. However, this should not preclude their civic responsibility to their local community and professional licensing body. In many countries with differing socio-cultural backgrounds, a medical doctor is often looked upon with high esteem—as a pillar of society and as a law-abiding professional with moral integrity. They should therefore take particular care not to offend the ethical and moral sensibilities of their local community, particularly in the field of new reproductive technologies, because this would obviously erode confidence and esteem of the medical profession, as well as disrupt solidarity of their local professional licensing body. Hence, any attempt by fertility doctors to exploit a legal loophole, by channelling local patients to foreign medical establishments which deal with commercialized gametes and embryos would ultimately represent flagrant disrespect and disregard for their local health authority, as well as for the socio-cultural and ethical values of their home country.
More importantly, because fertility doctors have received a licence to practice medicine in a particular country, it would therefore be their contractual as well as fiduciary obligation to uphold rather than undermine the ‘spirit and essence’ of any legislation pertaining to clinical practice in that country. It is often the case in many countries that the license to practice medicine is renewed annually, or once every few years, conditional upon the doctor agreeing to accept the jurisdiction of the local health authority and abiding by all legislation pertaining to clinical practice in that country, through a signed declaration form.
It must be remembered that particularly in the field of clinically assisted reproduction, there is much variation in the ethical standards and legislation governing clinical practice in different countries (Gunning, 2001; Schenker, 2003), probably due to cultural and religious differences. The problem is further compounded by the appearance of international chains of hospitals and clinics under the same management (MacStravic, 2004), which could facilitate the movement of both patients and medical professionals across international borders.
Obviously, it would be extremely challenging for legislators to control what patients and medical professionals do abroad. However, an initial step towards achieving this end would be to make it illegal for medical professionals to refer local patients overseas for gamete and embryo donation. Hefty penalties and fines may be imposed on recalcitrant medical professionals as a deterrent, in addition to censure and suspension of the licence to practice medicine. It could be advantageous to set up a special disciplinary board to deal with contravention of regulations pertaining to clinical assisted reproduction.
Whatever the case, it is imperative that fertility doctors should respect the laws and regulations governing clinical practice in their home country, and not attempt to exploit legal loopholes across international borders. If there is genuine widespread dissatisfaction against cumbersome and outdated regulations in their home country, then an attempt should be made through the proper channel to abolish or amend such regulations through the relevant local health authority.
References
Craft I, Johnson MH and Sauer MV (1997) Should egg donors be paid? Br Med J 314(7091),1400–1403.
Fortescue E (2003) Gamete donation—where is the evidence that there are benefits in removing the anonymity of donors? A patient’s viewpoint. Reprod Biomed Online 7,139–144.[Medline]
Gunning J (2001) Regulating assisted reproduction technologies. Med Law 20,425–33.[Medline]
Johnson M (1997) Payments to gamete donors: position of the human fertilisation and embryology authority. Hum Reprod 12,1839–1842.
MacStravic S (2004) The new era of international health care marketing for U.S. hospitals. Health Care Strategic Management 22,13–15.[Medline]
McMillan J and Hope T (2003) Gametes, money, and egg sharing. Lancet 362(9383),584.[CrossRef][Medline]
Pennings G (2004) Legal harmonization and reproductive tourism in Europe. Hum Reprod 19,2689–2694.
Sauer MV (1997) Reproductive prohibition: restricting donor payment will lead to medical tourism. Hum Reprod 12,1844–1845.[ISI][Medline]
Sauer MV (2005) Further HFEA restrictions on egg donation in the UK: two strikes and you’re out! Reprod Biomed Online 10,431–433.[ISI][Medline]
Schenker JG (2003) Ethical aspects of advanced reproductive technologies. Ann NY Acad Sci 997,11–21.
Sidebotham M (2003) Egg and sperm donation: an issue for health care professionals? J Fam Health Care 13,134–136.[Medline]
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