This
important blog describes the medical, ethical and legal aspects of reproduction
in the context of recent medical advances, the control of fertility and the
modern treatment of childlessness due to both male and female abnormality.
Legal and moral issues arising from surrogacy are also discussed, as are the
rights of the fetus – with particular attention being given to abortion, injury
and treatment in uterus and experimentation. Medico-legal aspects of parenting
include the dilemmas consequent upon the birth of a defective child and the
provision of treatment for children.
All
states of India have slightly different ethical values relating to surrogate
decision makers and advance directives. The commonly used names given to
surrogates and their powers are state specific with some surrogates having the
right to refuse medical treatment on behalf of the people who nominated them.
Similarly a range of different advance directives are used across India.
Important
medico-legal issues in relation to advance care planning include:
1.
Whether a patient is competent to make certain decisions;
2.
The legal status of written advance directives or any other statements that a
patient makes about their wishes for future care;
3.
The legal arrangements for formally appointing surrogate decision makers.
There
is significant burden associated with the role of surrogate decision-maker. A
systematic review examining how well surrogate decision-makers predicted the
patient’s wishes showed that they were accurate in two thirds of the cases. It
was suggested that “accuracy” may not be the only benefit which is important to
patients when relying on patient-designated surrogates.
Relationships
between health care providers and family members, and amongst the family
members themselves, have a significant impact on those who participate in end
of life decision making. An important area of potential conflict with surrogate
decision-makers is in the care of critically children.
In
regard to the role and use of surrogate decision-makers, there are significant
differences between practices in different national health systems, based on
how much focus there is on patient autonomy, the amount of formal reliance on
surrogate decision-makers, and the extent to which medical predominance in
decision-making is regarded as acceptable or as paternalistic. In some cultures
family-centered decision-making is valued much more highly than patient
autonomy.
The
role of the surrogate decision-maker is to try to ensure that any decisions
which are made about the patient’s care are consistent with what is known of
the patient's own values and wishes, and they should adhere to any documented
advance care plan. This may be difficult for family or friends who are dealing
with their own impending loss. Surrogate decision-makers experience
considerable stress in their role of supporting the patient. In order to
perform this role they need a very supportive relationship with the health care
providers caring for the patient, and adequate information.
While
formal arrangements for proxy decision-making focus on named individuals who
are appointed as surrogates, in practice many families make collective
decisions. In some families, there can be resistance to disclosing diagnosis
and prognosis to the patient, which makes advance care planning very difficult.
Skilled and sensitive communication is required to deal with these conflicting
perspectives, whilst at the same time ensuring that patients’ and families’ own
values are respected.
Surrogacy: General Considerations
& Guidelines for ART Clinics in India
1.
Surrogacy by assisted conception should normally be considered only for
patients for whom it would be physically or medically impossible / undesirable
to carry a baby to term.
2.
Payments to surrogate mothers should cover all genuine expenses associated with
the pregnancy. Documentary evidence of the financial arrangement for surrogacy must
be available. The ART centre should not be involved in this monetary aspect.
3.
Advertisements regarding surrogacy should not be made by the ART clinic. The
responsibility of finding a surrogate mother, through advertisement or
otherwise, should rest with the couple, or a semen bank.
4.
A surrogate mother should not be over 45 years of age. Before accepting a woman
as a possible surrogate for a particular couple’s child, the ART clinic must
ensure (and put on record) that the woman satisfies all the testable criteria
to go through a successful full-term pregnancy.
5.
A relative, a known person, as well as a person unknown to the couple may act
as a surrogate mother for the couple. In the case of a relative acting as a
surrogate, the relative should belong to the same generation as the women
desiring the surrogate.
6.
A prospective surrogate mother must be tested for HIV and shown to be
sero-negative for this virus just before embryo transfer. She must also provide
a written certificate that (a) she has not had a drug intravenously
administered into her through a shared syringe, (b) she has not undergone blood
transfusion; and (c) she and her husband (to the best of her/his knowledge) has
had no extramarital relationship in the last six months. This is to ensure that
the person would not come up with symptoms of HIV infection during the period
of surrogacy. The prospective surrogate mother must also declare that she will
not use drugs intravenously, and not undergo blood transfusion excepting of
blood obtained through a certified blood bank.
7.
No woman may act as a surrogate more than thrice in her lifetime.
8. A child born through surrogacy must be
adopted by the genetic (biological) parents unless they can establish through
genetic (DNA) fingerprinting (of which the records will be maintained in the
clinic) that the child is theirs.
