Event: ‘Passport to Parenthood’

Speakers at Progress Educational Trust’s annual conference in London examined the evidence and ethics on cross-border reproductive care. Jennie Bristow reports.

Introducing the conference Sarah Norcross, director of Progress Educational Trust, noted the range of people interested in the issue of cross-border reproductive care (CBRC). The conference focused on patients seeking fertility treatment, and paid particular attention to UK citizens travelling to the USA and Europe. However, as evident from the conference’s attendees, the issues involved in CBRC are of interest to academics, clinicians, lawyers, journalists and those working in the broader field of reproductive healthcare, as well as to patient groups. 

The evidence behind cross-border reproductive care

A presentation by Dr Françoise Shenfield, Clinical Lecturer in Infertility and Honorary Lecturer in Medical Ethics at University College London’s Medical School, discussed the findings of her study of CRBC in Europe. Those seeking treatment overseas do so for reasons closely tied to the problems with fertility treatment in their own countries: so the main reason for travelling from Italy is that the provision of treatment is so heavily restricted by law; in France, it is that clinics are not allowed to treat single women or lesbians. People trend to travel from Britain overseas because of difficulties in accessing treatment and expectations of better quality care overseas. The price of an IVF cycle in Belgium, noted Shenfield, is half what it is in London.

Lorraine Culley, Professor of Social Science and Health and Associate Director of the Mary Seacole Research Centre at De Montfort University, discussed findings from her qualitative study of people’s motivations and experiences of CBRC. Culley noted a wide and complex range of reasons. The most common factor was the need for treatment with third party gametes, and the length of waiting lists in the UK. Some felt that seeking treatment abroad would provide a more pleasant environment, as they could get away from the everyday stresses of undergoing treatment in the UK, and were attracted by the promise of better success rates - although they remained sceptical of some of the claims. However, for most couples going abroad was the last resort, following an experience of having had treatment in the UK already.

Addressing the question of whether CBRC was a problem or a solution, Culley argued that for people who struggle to get treatment in the UK, it is a solution with some clear problems, related to the variety of regulations surrounding surrogacy, multiple pregnancy, and donor welfare. She argued that there was a danger in media reports of scapegoating patients, ignoring economic and political issues surrounding IVF. The discussion should not only be about educating patients, she said, but should also be about professional responsibility and fixing systemic problems in UK.

Who oversees overseas?

Dr Evan Harris, adviser to the Social Liberal Forum and former Liberal Democrat Shadow Science Minister, chaired a session examining regulatory issues. Juliet Tizzard, Head of Policy at the Human Fertilisation and Embryology Authority (HFEA), said that from the HFEA’s point of view giving patients information about treatment abroad, or referring them to particular clinics, is fine. A more complicated question arises in relation to the possibility of shared care arrangements between UK clinics and those abroad. Might the HFEA want to produce some guidance, or restrict or prohibit some activities?

Tizzard explained that the HFEA commissioned legal advice to see where its legal remit starts and finishes, which found that the regulator has almost no power in relation to clinics treating abroad, because this is not treatment that it licenses. There is some concern, noted Tizzard, that UK policies and regulations might be driving people to seek treatment abroad, for example by causing long waiting lists. This is part of the reason behind the HFEA’s launch, in January 2011, of a new consultation on donation. So far as possible, argued Tizzard, it is preferable for UK citizens to have treatment here.

Natalie Gamble, Partner at Gamble and Ghevaert, talked about the legal issues and pitfalls for families conceived through cross-border fertility treatment. The fact that the globe is made up of so many different jurisdictions and regulations raises some difficult legal issues, Gamble argued, especially in relation to gamete donation and surrogacy. Gamble highlighted the area of donor information rights, where there are myriad different approaches to the donor information available to children once born, and these are determined by the country of conception. For example, Spain provides very limited information about donors, while the USA has an open donation approach that provides more information than the UK.

Gamble also discussed the legal issues around ‘parenthood’, that is ‘making sure you are going to be treated as your child’s legal parent once the child is born’. She raised the problem of sperm donation cases in which the non-biological parent is treated as the parent if the couple is married; if they are not married, they need to sign a form at the HFEA before treatment, but they cannot do this if they are having the treatment overseas. To gain the status of the legal parent, couples either need to marry before conception or apply for step-parent adoption after the birth.

Surrogacy, argued Gamble, is one of most sensitive fertility treatment issues, and there are enormous disparities, with the practice banned in some countries or commercially allowed in others, with the UK in the middle. There is a lack of international harmonization about law on who is legal parent. For example, Gamble talked about the case of X&Y – a British married couple who underwent commercial surrogacy in the Ukraine. Twins were born, all parties were happy with the arrangement, and the British couple were named on the birth certificate in Ukraine, but British law did not recognise the couple as parents. So the twins were born ‘stateless and parentless’.

James Lawford-Davies, Partner at Lawford Davies Denoon, discussed how the European Union has the approached question of cross-border reproductive care. He noted two key principles within European regulation: the free movement of persons; and freedom to provide services within internal market. He pointed to the intention to assure quality across the EU, providing patients with the confidence that services abroad have reached minimum standards, and he also stated that the directive does not exempt IVF or reproductive health care. Lawford-Davies argued that CBRC is no panacea – particularly for patients obtaining treatment abroad that it is illegal in their own country. Member states can prohibit treatments. However, the freedom to travel is a positive feature, and the focus on quality is welcome.

Zeynep Gürtin-Broadbent, Research Fellow at the Centre for Family Research at the University of Cambridge, discussed ‘the ethics of coerced conformity’ in regulating CBRC. She noted that relates to a range of phenomena, and that there are different issues in relation to whether one is talking about patients or donors, and the diverse reasons why people might seek treatment abroad. The question of ‘who overseas overseas?’ should have different answers depending on which aspects of the phenomenon are being addressed: for example, regulators might be best placed to address legal questions, while referring physicians or clinics might be best placed to address for safety concerns. Regulators could also think about the policies that are driving patients overseas, and how rules could be harmonized. Depending on the circumstances, she argued, CBRC could be a personal solution or a major international problem.

Having a child: how far should you go?

A session on the ethics of CBRC was chaired by Lord Naren Patel, Vice-Chair of the All Party Parliamentary Groups on Infertility and Maternity. Professor Naomi Pfeffer, Honorary Fellow at University College London’s Department of Science and Technology Studies, argued that the global market for human eggs is a ‘rotten trade’, taking advantage of women in countries where nothing is done to remedy the ‘negative externalities’ of egg donation. The rapid growth in egg donation market is attributed to restrictions in home countries, but, she argued, the consciences of would-be egg buyers need to be pricked, and the international community should acknowledge that the global market in human eggs is a significant problem, in the way that it does with live donors selling kidneys.

Stuart Lavery, Director and Person Responsible of IVF Hammersmith, described his experience in dealing with patients who have had cross-border reproductive care, most of whom had ‘reached the end of the line’ in UK treatment leaving egg donation as the only option. Hammersmith hospital provided 1,400 NHS cycles last year, of which only 10 were egg donation cycles: this indicates why the majority of patients fall within the private sector. There have been long-standing problems with obtaining eggs in the UK, fuelled by the laws on donor anonymity and compensation, Lavery argued; and these led patients to go overseas with minimal information and having negative experiences of care.

In 2007, Lavery’s clinic visited a variety of clinics overseas, and formed relationships with two of them to provide CBRC. Two hundred and fifty-one patients have been treated in this way over past two years and ‘the bottom line is, it works’: the pregnancy rate is 66% per cycle. Is it safe? Lavery acknowledged that there have been some problems with multiple pregnancies, but these were addressed. Ethical issues have also been considered, through compensation, screening and counselling. Although CBRC is in many ways ‘an enormous problem’, it can be a solution in desperate circumstances, and if done properly it can be safe and ethical way to help some couples have families.

Janet Radcliffe Richards, Professor of Practical Philosophy at the Oxford Uehiro Centre for Practical Ethics, argued that there are ‘two completely different things that go under the name of ethics’: having a set of values that you abide by, and trying to decide which of these principles we should have. People’s rushes to judgment in moral matters seem to be very much about what they see people doing, but we need to think if these things are justifiable in the long term. Why is it that we object to people being paid to donate their eggs – is it because of payment or exploitation? In principle, she argued, the matter of payment, like the question of egg-sharing, could be beneficial to both sides – so why outlaw it altogether rather than make it better for both sides?

‘We have a lot of instinctive reactions about things that are unfamiliar to us, and use this unease to start by blocking things,’ Radcliffe Richards said: but the onus should be on us to demonstrate positive harm before we forbid these things, and look to how we can ‘stop with bad without stopping the good at the same time’. She concluded: ‘Ethics is much tougher than it looks – it is not just about feeling comfortable’. 

Detailed reports on the ‘Passport to Parenthood’ conference are published by BioNews, here. The conference programme can be viewed here.