Beginning of life

Question 1

Who regulated fertility treatment?

Answer 1

Human fertilisation and embryology act 1990 (revised 2008)

Question 2

What are the current NICE criteria for fertility treatment?

Answer 2

Women under 40 who have been trying for more than 2 years should be offered 3 full cycle of IVF
Women aged 40-42 should be offered 1 cycle of IVF provided they’ve had no previous cycles, they have no evidence of low ovarian reserve and they are made aware of risks
Treatment is only recommended in women with BMI 19-30

Question 3

What other criteria might be imposed by the CCG for fertility treatment?

Answer 3

Only for explained fertility problems
More time before treatment offered
Stringent BMI and age restrictions
Non smoking women
No partner must have another living child

Question 4

What must be taken into account before fertility treatment?

Answer 4

The welfare of any child that may be born as a result of the licensed treatment provided by the clinic and any other child who may be affected by that birth
Presumption in favour of providing treatment for those that seek it unless evidence to the contrary (prev convictions of harming children/addiction/inheritable genetic diseases)

Question 5

In 2008 what replaced the ‘need for a father’?

Answer 5

The need for ‘supportive parenting’

Commitment to the health, wellbeing and development of the child

Question 6

What happened to donors in 2004?

Answer 6

Any child resulting from gamete donation after April 2005 has the legal right to receive information about the donor when they reach the age of 18
eg name, DOB, physical characteristics and last known address

Question 7

What about rights to have a child?

Answer 7

There is a ‘right to found a family’ in the European Convention on Human Rights but this is not an absolute right

Question 8

Name 2 common fertility treatments for same-sex couples

Answer 8

DIY insemination at home (lesbians using donor sperm from male friend/online donor)
Formal surrogacy for gay men
But not funded by NHS as most CCGs don’t fund use of donor gametes, irrespective of sexuality

Question 9

Who are the legal parents in same sex couples?

Answer 9

After April 2009, both parents can be named on the birth certificate and be entitled to parental responsibility as long as the couple were in a civil partnership at the time of conception or the child was conceived via fertility treatment at a licensed clinic.
In lesbian couples, the non biological mother is ‘parent’

Question 10

What about fostering and adopting in same sex couples?

Answer 10

In 2005 it became legal for same sex couples to adopt/foster as a couple (rather than as individuals)

Question 11

Is surrogacy legal?

Answer 11

Commercial surrogacy is illegal, no enforceable contract can be made between surrogate and the commissioning couple
Otherwise it is legal, and reasonable expenses can be paid for
?can a child be a trade item? ?health risks for surrogate mum? ?coercion of relatives?

Question 12

What are the 2 types of surrogacy?

Answer 12

Traditional (surrogate uses her own eggs and is the biological mother but conceives with sperm from the intended father)
Host surrogacy (an embryo is created via IVF from the commissioning couple, the embryo is implanted into the surrogate so she therefore has no biological link to the child

Question 13

Who is the legal mother of the child when surrogacy is used?

Answer 13

The surrogate is the legal mother of the child, irrespective of genetic make-up, until a parental order is granted. This is usually between 6weeks-6moths of age

Question 14

What is a pre-implant diagnosis?

Answer 14

Embryos created via IVF are tested in vivo for a genetic mutation
An unaffected embryo is chosen for implantation (CANNOT choose an affected embryo)
Eradicates mutation for future generations
The genetic condition needs to be sufficiently serious for a licence
An alternative to prenatal diagnosis & termination of pregnancy
?does a fetus have greater moral value than an embryo?

Question 15

What diseases can pre-implant diagnosis be used for?

Answer 15

‘If there is significant risk that the child to be born will have/develop a serious illness or disability’
Huntington’s
BRCA1 and 2
Certain deafness mutations etc

Question 16

Why can abortion be seen as immoral?

Answer 16

Direct conflict between a woman’s reproductive autonomy and the right to life of the fetus
‘All life is sacred’
‘Life begins at conception’
Is a fetus a person? Fetus is a potential person, and every ‘person’ has the right to life (but then are eggs and sperms potential persons… potential to generate future life?)
Or does a fetus gain a right to life at viability? (22 weeks)
Form of eugenics (eg screening out Down’s)

Question 17

When is abortion legal?

Answer 17

In the following circumstances when 2 doctors in good faith agree that grounds exist:

• The pregnancy has not exceeded its 24th week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family
• The termination of pregnancy is necessary to prevent grave permanent injury to the physical or mental health of the woman
• The continuance of the pregnancy would involve risk to the life of the pregnant woman greater than if the pregnancy was terminated
• That there is a substantial risk that if the child was born it would suffer from such physiological or mental abnormalities as to be seriously handicapped

Question 18

Why is terminating a pregnancy due to the risk that the child would be born with disability an ethical issue?

Answer 18

The likelihood of risk and nature of the risk is difficult to know as a definitive diagnosis sometimes cannot be made
No definition of serious disability
‘Disabilist’ view

Question 19

What rights does the father have in decisions about abortion?

Answer 19

None
He cannot insist she carries on with the pregnancy, nor can he insist she aborts.
It is the woman’s body (the fetus has no legal rights)

Question 20

If you, as a doctor, strongly disagree with abortion, can you disagree to letting your patient undergo it?

Answer 20

You are permitted to refuse to ‘participate in treatment’ by virtue of a conscientious objection except when treatment is necessary to save the life or prevent grave permanent injury to the pregnant woman.
This is only for ‘hands on’ participation so you still have a duty to signpost the patient to the appropriate services

Question 21

Is a woman morally or legally responsible for the harm she causes her child in utero?

Answer 21

The mother has moral duty to the unborn child due to the impact her actions have on the future wellbeing of her child
The fetus has no legal rights until birth. No claim can be made against the mother for things that happen in utero (eg consuming alcohol)
However parents can be sued by the child, once born, for disabilities which occurred before birth as a result of a breech of duty as a parent

Question 22

Can doctors be sued for pre-natal negligence?

Answer 22

Yes if the negligence results in harm to the child when born

Question 23

What is the guidance for resuscitation of severely premature babies and intensive care?

Answer 23

Offer full CPR at birth at 25 weeks gestation
At earlier gestations the probabilty of success is lower so decision made on a case by case basis
At 24 weeks a baby should be offered full invasive intensive care and support unless the parents AND clinicians are agreed that it is not in the baby’s best interests

Question 24

When should treatment be limited in neonates and children?

Answer 24

RCPCH guidance outlines 3 situations:
When their life is limited in quantity (death is imminent or inevitable)
When life is limited by quality (burden of treatment/suffering outweighs any benefit from sustaining life
When there is competent refusal by an older child/adolescent, supported by parents and clinicians

Question 25

What should be considered when discussing limiting treatment in life-limiting conditions in children?

Answer 25

Child's quality of life (or predicted QoL)
Parent's values
Sanctity of life? Right to life?
Child's dignity
Burden of treatment/suffering
Justice of futile treatment versus using resources for other patients (NICE says this should not matter at an individual level)
Capacity for independent survival
Pleasure/interaction with others

Question 26

What are the ethical issues surrounding assisted reproduction?

Answer 26

• If life starts at conception, how can you licence the destruction of unused embryos
• Not natural
• Everyone’s right to have a child?
• Is it a medical problem?
• Expensive: equal access, distributive justice. CCGs change rules in different areas “postcode lottery”
• Not a rigorous process for IVF, unlike becoming a foster parent.
• Creation & selection of embryos.

Question 27

Who has parental responsibility when a surrogate child is born?

Answer 27

The surrogate mother and her husband until the baby is formally passed over

Question 28

Ethical arguments about conscientious objection

Answer 28

• Duty as a doctor to treat patient, do what is in the interests of the patient. If not willing to treat then shouldn’t be a doctor?
• Gives slant of ‘doing wrong’ to the patient, shouldn’t make patient feel judged.
• Makes them unable to provide the service they are objecting to (no practice, what about in an emergency?)
• Discrimination against certain patient groups?
• Basic liberal principle.

Question 29

Abortion law in Northern Ireland?

Answer 29

• Medical abortion up to 9 weeks
• Only possible if there is “a threat to the life of the woman, or a risk of real and serious adverse effect on her health, which is either long term or permanent”

Question 30

Is a TOP legal on the grounds of fetal sex?

Answer 30

“Abortion on the grounds of gender alone is illegal”
➢ Not if it will cause mental health injury
➢ X-linked conditions are allowed

Question 31

If a baby is born at 22+0 - 22+6, what treatment is required?

Answer 31

None is required by law

Generally DNR

Question 32

If a baby is born at 23 weeks, what treatment is done?

Answer 32

Wishes of parents
Clinicians are not obliged to resuscitate
Use clinical judgement

Question 33

If a baby is born at 24 weeks, what treatment is done?

Answer 33

Full support is offered
NICU
Unless both parents and clinicians agree otherwise (Nuffield Guidance)