Moral Deliberation about Fertility Treatment for HIV-1 Serodiscordant Couples

In his article "Providing Fertility Care to Those With HIV: Time to Reexamine Healthcare Policy," Mark V. Sauer (2003) discusses the history and justification of Columbia University's program for providing reproductive assistance to couples who want biologically related offspring when the male partner is human immunodeficiency virus type 1 (HIV-1) positive and the female partner is not. Fortunately, Sauer and the ethics committee at Columbia Presbyterian Medical Center came to a conclusion that is, in some respects, morally defensible. They courageously moved forward with providing sperm-washing technology to U.S. couples when few other U.S. programs were willing to do so. Sauer's moral reasoning and his presentation of the discussion of the Ethics Committee, however, do not adequately delineate the moral issues raised by this technology and thus provide little moral guidance.

According to Sauer's discussion of the literature, by 1997 it was clear that with careful application of appropriate techniques serodiscordant couples could achieve a pregnancy with very little risk of transmitting HIV-1 to either the woman or the offspring. In fact there had not been any transmissions of disease in any of the numerous procedures that had been performed. Sauer brought the issue of studying the efficacy of using washed sperm for in vitro fertilization of retrieved eggs through intracytoplasmic sperm injection (IVF-ICSI) before the institutional review board (IRB) and the ethics committee of Columbia Presbyterian Medical Center. From the little he says, I presume that the IRB reviewed the study design issues while the ethics committee was asked to review whether it was ethically acceptable to offer the therapy. In his article Sauer shares the discussion of the ethics committee.

An Ethical Analysis of the Issues

From Sauer's account it is not easy to discern which moral question the Columbia ethics committee thought they were deciding, but there are two distinct core ethical issues involved in the decision that was before them. One was whether any reproductive assistance should be offered to serodiscordant couples. The other was which procedure should be offered. Each question deserved its own careful ethical analysis.

The answer to the first question turns on an understanding of the scope of medicine. Although the bioethics literature is replete with discussions that presume the scope of medicine to be defined by a concept of health or normal human function, that limited view is problematic, and reproductive medicine presents it with a formidable challenge. As I have previously argued, a shared sense that some goal can be important to people (e.g., having a biologically related child, ending a pregnancy), coupled with medicine having the unique set of knowledge, powers, and privileges to address the concern, puts a treatment (e.g., assisted reproduction, abortion) squarely within the bounds of medicine (Rhodes 2001). This appreciation gives medicine the responsibility to provide treatment when it will be of value in the eyes of the patient. The only limit to the responsibility to provide treatment is, typically, evidence that the treatment will do significantly more harm than good and thereby undermine society's trust of medicine as an institution. An example of a legitimate refusal to provide treatment in accordance with a patient's request would be the refusal by an organ transplant program to comply with the request of an eager living donor to remove her heart or second kidney for transplantation. The seriousness and certainty of harm to the donor and to the trustworthiness of medicine justifies denying the request for the medical intervention.

On the one hand, Sauer appreciates that the powerful desire for a biologically related child—together with the desire to avoid inflicting HIV, a life-threatening disease, on offspring—provides a strong justification for making the services available to those who want them. Furthermore, because sperm-washing techniques make disease transmission to the woman and child far less likely, averting the...