Ethical and Practical Considerations of Perimortem Gamete Procurement for Palliative Care Providers.

Requests for perimortem gamete procurement (PGP) typically arise by a surrogate decision maker after the unexpected death or incapacitation of a reproductive-aged individual. Palliative care clinicians should have a working knowledge of the medical, ethical, and practical considerations pertaining to such requests. In this paper, we describe a case in which the PGP request originated from an incapacitated patient's parents. We review the technologies associated with PGP and posthumous assisted reproduction (PAR) and discuss the ethical and legal issues involved in such cases, including recent position statements from national and international reproductive health groups. Finally, we provider readers with a stepwise approach for considering requests for PGP.

Single men's attitudes towards posthumous use of their sperm cryopreserved due to illness in Israel.

BACKGROUND: Banking of frozen spermatozoa by single men opens the possibility of procreation long after their death. Requests for posthumous reproduction by the families of the deceased are growing, raising an ethical debate, especially when written instructions were not left by the patients and in cases of unplanned perimortem collection. The issue of the progenitors' intention to procreate after death is the key to ethically based decision-making in these cases. OBJECTIVES: To evaluate the attitude of single men cryopreserving spermatozoa before life-threatening medical situations towards post-mortem usage of their cryopreserved spermatozoa. MATERIALS & METHODS: Adult single men prior to sperm cryopreservation before cytotoxic therapy were asked to sign a structured form declaring their will and instructions for the usage of their cryopreserved spermatozoa in case of their demise. RESULTS: Four hundred fifty-two men of diverse ethnicity, religious and cultural backgrounds signed the form providing instructions for the use of their cryopreserved spermatozoa in case of mortality. Their age was 27.4 ± 8.06 years. Seven (1.5%) patients willed their spermatozoa for posthumous reproduction to a sibling, 22 (4.9%) to parents, and 26 (5.7%) to their informal female partners. The significant majority (n = 397; 87.8 %) of the single men were ordered to destroy their cryopreserved spermatozoa in case of their expiry. Note that, 26-39 years old men were less likely (81.8% vs. >90% in other ages) to order sperm destruction, as well as men with a poorer prognosis (83% vs. 90%). DISCUSSION: In this study group, most single men cryopreserving spermatozoa in the face of future life-threatening morbidity do so for their own future live parenthood, and are not interested in posthumous reproduction. CONCLUSION: Our results doubt the claim that single men who had an unplanned perimortem sperm collection can be universally presumed to have wished to father a child posthumously. Any claimed assumed consent in these cases should be considered for each case individually based on its specific circumstances.

Leaving a Legacy: Allied Health Professionals' Perceptions of Fertility Preservation and Posthumous Reproduction for Adolescent and Young Adults with a Poor Cancer Prognosis.

Purpose: To explore Allied Health Professionals' (AHPs) experiences with and perceptions of posthumous assisted reproduction (PAR) among adolescent and young adults (AYA, ages 15-39) with a poor cancer prognosis. Methods: We conducted a qualitative analysis of video-based 90-minute focus groups (FGs) of AHPs who participated in the Enriching Communication Skills for Health Professionals in Oncofertility (ECHO) training program from May to August 2021. Moderator-facilitated discussions were guided by topics related to experiences around discussions and utilization of PAR among AYA with a poor cancer prognosis. Thematic analysis was conducted using the constant comparison method. Results: Forty-three AHPs participated in one of seven FGs. Three themes emerged: (1) PAR as palliative care: preserving patient's legacy for their partner, siblings, and parents; (2) ethical and legal considerations for balancing patient's time-sensitive needs; and (3) barriers AHPs encounter navigating complex dynamics of care in this population. Subthemes included an emphasis on patient autonomy, a multidisciplinary approach to counseling, early initiation of fertility discussions continuing over time, documenting reproductive desires, and concerns for family and offspring after patient death. Conclusions: AHPs desired timely conversations on reproductive legacy and family planning. In the absence of institutional policies, training, and resources, AHPs emphasized feeling ill-equipped to navigate the complex dynamics between patients, families, and colleagues. The development of transparent institutional policies, implementation of multidisciplinary care teams, and oversight with ethics committees may improve the provision of reproductive health care and/or end-of-life care for AYA with a poor cancer prognosis and their families.

Perspectives surrounding fertility preservation and posthumous reproduction for adolescent and young adults with terminal cancer: Survey of allied health professionals.

BACKGROUND: While all reproductive-aged individuals with cancer should be offered fertility preservation (FP) counseling, there is little guidance over offers to adolescent and young adults (AYA) with terminal diagnoses, especially when considering posthumous assisted reproduction (PAR). The Enriching Communication skills for Health professionals in Oncofertility (ECHO/ENRICH) trains Allied Health Professionals (AHPs) to improve communication with AYAs with cancer. Little is known about AHPs' role in assisting in FP and PAR decisions. METHODS: This is a cross-sectional survey of ECHO/ENRICH trainees' attitudes and experience with FP and PAR in AYA with terminal cancer. RESULTS: The response rate was 61% (365/601). While 69% felt comfortable discussing FP with terminal AYA after ECHO/ENRICH training, 85% desired further education. The majority (88%) agreed FP should be an option for AYA with cancer, though some agreed offering FP provided false hope (16%) or was a waste of resources (7%). Most shared that avoidance of FP discussions was common practice, especially in the medically fragile, late-stage disease, or among minors. Many attributed lack of conversations to oncology team goals. Only 9% had prior experience with PAR. Many were conflicted about how PAR reproductive material should be gifted and who should be permitted to use PAR. Several raised moral concerns for PAR, or discomfort advising family. Many voiced desire for additional PAR-specific education. CONCLUSION: ECHO/ENRICH trainees had varied levels of exposure to FP in terminal AYA and limited experiences with PAR. Many expressed uncertainties with PAR, which may be alleviated with further training and transparent institutional policies.

Inseminação artificial homóloga póstuma: análise bioética do planejamento familiar / Posthumous homologous artificial insemination: a bioethical analysis of family planning / Inseminación artificial homóloga póstuma: un análisis bioético de la planificación familiar

Resumo Este artigo trata de questões relacionadas à inseminação artificial homóloga post mortem. Tomando como referência normas éticas que asseguram a livre escolha do casal no planejamento familiar, objetivou-se descobrir de que forma tais regulamentações influenciariam na concretização desse projeto parental. A partir do método hipotético-dedutivo, realizou-se revisão de literatura em bioética e biodireito, além de pesquisa documental no sítio eletrônico do Conselho Federal de Medicina. Refletiu-se, então, sobre o princípio de autonomia dos pacientes submetidos às técnicas de reprodução assistida, levando em conta algumas das repercussões dessa técnica sobre o direito de família e sucessões. Por fim, descreveu-se o método de casuística clínica, utilizado pelas clínicas como parâmetro para tomar decisões e aconselhar o cônjuge sobrevivente acerca da problemática da concepção póstuma.

Abstract This article discusses issues related to post mortem homologous artificial insemination. Taking as reference ethical norms that ensure the couple's free choice in family planning, the objective was to understand how such regulations would influence the accomplishment of this parental project. Using the hypothetical-deductive method, a literature review on bioethics and biolaw was carried out, in addition to a documentary research on the website of the Federal Council of Medicine. Then, reflections on the principle of autonomy of patients undergoing assisted reproduction techniques were made, considering some of the repercussions of this technique on family and succession law. Finally, a description of the method of clinical casuistry is presented, being used by clinics as a parameter to make decisions and advise the surviving spouse about the problem of posthumous conception.

Resumen Este artículo trata aspectos relacionados a la inseminación artificial homóloga post mortem. Con base en la normativa ética que garantiza la libre elección de la pareja en la planificación familiar, el objetivo fue identificar la influencia de la legislación en la realización de este proyecto parental. A partir del método hipotético-deductivo, se realizó una revisión bibliográfica sobre bioética y bioderecho, además de una búsqueda documental en el sitio web del Consejo Federal de Medicina. Con esto, se reflexionó sobre el principio de autonomía de los pacientes sometidos a técnicas de reproducción asistida, teniendo en cuenta algunas de las repercusiones de esta técnica en el derecho de familia y de sucesiones. Por último, se describió el método de la casuística clínica utilizado por las clínicas como parámetro en la toma de decisiones y asesoramiento al cónyuge sobreviviente en el tema de la concepción póstuma.

Parents' posthumous use of daughter's ovarian tissue: Ethical dimensions.

In recent years, progress in cancer treatment has greatly increased the chances of recovery. Yet, treatment may have irreversible effects on patients' fertility. In order to protect future fertility, preservation of ovarian tissue may be offered today even to very young girls, involving a surgical procedure that may be performed by minimally invasive laparoscopy, under general anesthesia. However, in the tragic event of a girl's death, questions may arise regarding the possible use of the preserved ovarian tissue by her parents. Should posthumous reproductive use of ovarian tissue without the girl's prior consent (due to her young age) be considered a violation of her rights? On the other hand, can it be argued that it is in the interest of a child who died young to leave a genetic trace through posthumous reproduction, because genetic continuity is in the interest of every human being? After presenting the relevant clinical facts, we explore the ethical dimensions of this possible practice through an analysis of the interests of the deceased, her parents, and the child that may be born posthumously.

Ethical Barriers in Adolescent Oncofertility Counseling.

Adult survivors of pediatric cancers are at substantial risk for infertility. Oncofertility is an emerging field in medicine that has focused on the fertility preservation of these patients. As the field continues to develop, there are several areas in which our practice has improved. However, several ethical concerns still exist involving beneficence, nonmaleficence, informed consent, adolescent assent, and posthumous use of reproductive tissues. Because the field is still developing, great disparities exist in available options depending on age, ability to pay, and geographic location. Such discrepancies in access may lead to health disparities in the adolescent patient population. As the science continues to make future fertility more feasible, the ethical questions will continue to be more complex. The purpose of this article is to review some of the developments regarding oncoferility and address future directions for research and inquiry in specific areas.

Ethical quandaries in gamete-embryo cryopreservation related to oncofertility.

While cancer rates continue to increase, therapy has dramatically decreased the mortality rates. The increased efficacy of current therapies may unfortunately have profound toxic effects on gamete function in both adolescent and reproductive age groups, with infertility as an expected consequence of cancer therapy. Significant progress in the advancement of fertility preservation therapies provides realistic options for future fertility in cancer survivors. However, a number of challenging issues need to be considered when presenting fertility preservation options. This overview highlights some of these considerations including religious-cultural-ethical values, access to care and cost of services, developmental capacity and consent, and posthumous reproduction.

Posthumous sperm utilization in men presenting for sperm banking: an analysis of patient choice.

The question remains as to whether or not men would agree to posthumous sperm use for pregnancy initiation. Often, these individuals' lives are suddenly interrupted and prior consent is rarely given. Therefore, post-mortem retrieval or use of these spermatozoa remains controversial and the incidence of consent for post-mortem sperm use is not clear. Men who bank spermatozoa, however, represent a cohort that can be examined for frequency of consent for post-mortem sperm use. We performed a retrospective chart review for 364 patients presenting for sperm banking at a single institution from 2009 to 2011. Banked specimens represented either ejaculated or surgically retrieved spermatozoa. Demographic information was obtained for each patient and men were grouped by reason for sperm banking, relationship and paternity status, and consent for post-mortem sperm use. The frequency of post-mortem consent was determined within each group. Men were grouped based on reason for banking, including infertility ('Infertility') or malignancy prior to treatment ('Cancer'). Mean ± SD age of the infertility and cancer groups were 40.1 ± 9.9 years and 27.1 ± 9.6 years, respectively. Of the 364 men, 85.9% provided consent for post-mortem sperm use. In the infertility group, 87.4% of men consented. Of these, 92.9% men in a relationship and 62.5% single men consented. Regarding paternity status, 64.7% men with and 56.6% men without children consented. Within the cancer cohort, 83.8% men consented. Of men <18 years old and ≥18 years old, 65.2 and 85.8% consented, respectively. Relationship status yielded 93.2% men in relationships and 79.4% single men consenting. Paternity status in the cancer group yielded 95.8% with and 82.4% men without children consenting. In summary, most men presenting for sperm banking provided consent for post-mortem sperm use, irrespective of reason for banking. Men who are in a relationship or who are fathers were more likely to agree to post-mortem sperm use.

Teaching medical ethics and law.

The teaching of medical ethics is not yet characterised by recognised, standard requirements for formal qualifications, training and experience; this is not surprising as the field is still relatively young and maturing. Under the broad issue of the requirements for teaching medical ethics are numerous more specific questions, one of which concerns whether medical ethics can be taught in isolation from considerations of the law, and vice versa. Ethics and law are cognate, though distinguishable, disciplines. In a practical, professional enterprise such as medicine, they cannot and should not be taught as separate subjects. One way of introducing students to the links and tensions between medical ethics and law is to consider the history of law via its natural and positive traditions. This encourages understanding of how medical practice is placed within the contexts of ethics and law in the pluralist societies in which most students will practise. Four examples of topics from medical ethics teaching are described to support this claim. Australasian medical ethics teachers have paid less attention to the role of law in their curricula than their United Kingdom counterparts. Questions like the one addressed here will help inform future deliberations concerning minimal requirements for teaching medical ethics.

Physicians' undecided attitudes toward posthumous reproduction: fertility preservation in cancer patients with a poor prognosis.

BACKGROUND: The American Society for Clinical Oncology (ASCO) established guidelines for fertility preservation for cancer patients. In a national study of US oncologists, we examined attitudes toward the use of fertility preservation among patients with a poor prognosis, focusing on attitudes toward posthumous reproduction. METHOD: A cross-sectional survey was administered via mail and Internet to a stratified random sample of US oncologists. The survey measured demographics, knowledge, attitude, and practice behaviors regarding posthumous reproduction and fertility preservation with cancer patients of childbearing age. RESULTS: Only 16.2% supported posthumous parenting, whereas the majority (51.5%) did not have an opinion. Analysis of variance indicated that attitudes toward posthumous reproduction were significantly related to physician practice behaviors and were dependent on oncologists' knowledge of ASCO guidelines. CONCLUSIONS: Physician attitudes may conflict with the recommended guidelines and may reduce the likelihood that some patients will receive information about fertility preservation. Further education may raise physicians' awareness of poor-prognostic patients' interest in pursuing this technology.

Bottled babies and frozen hope: a review of three recent decisions on the property of cryopreserved sperm.

The English common law has taken a deliberate step away from the Australian High Court's longstanding "work or skill" exception to the rule against proprietary claims over the human body. Now, at least in respect of cryopreserved sperm, the English Court of Appeal has recognised a proprietary interest arising from a principle of "subsisting right to use". However, recent Australian decisions illustrate the ongoing role of the "work or skill" exception in circumstances where a widow seeks access to her deceased husband's sperm to conceive a child. If such claims are to be made within a property law paradigm, as it appears they must, then Australian courts should supplement the all too easily satisfied "work or skill" exception with a clear and robust outline of discretionary considerations.

Posthumous reproduction and palliative care.

Posthumous reproduction is an issue fraught with legal, ethical, religious, and moral debate. The involvement of the hospice and palliative care community in this debate may be peripheral due to the fact that other health care professionals would be actually delivering the services. However, the hospice and palliative care community are more likely to treat patients considering posthumous reproduction as they near the end of their lives. This article provides the hospice and palliative care community with a review of the medical, ethical, and legal considerations associated with posthumous reproduction. Having knowledge of these issues, and a list of available resources, will be useful if hospice and palliative care staff find themselves facing a patient or family that is considering posthumous reproduction.

Cancer and fertility: ethical and legal challenges.

Preserving the fertility of younger cancer patients requires coordinated efforts and attention to ethical issues by oncologists and fertility specialists. Although sperm is easily stored, freezing eggs or ovarian tissue is still experimental and should not be offered except as part of an experimental protocol. When gametic material is stored for later use, written directives for posthumous use may be given effect, and subsequently born children may be recognized as legal offspring of the deceased. Concerns about the welfare of offspring resulting from an expected shortened life span of the parent are not sufficient reason to deny cancer survivors assistance in reproducing.

Legal issues related to parenthood after cancer.

Cancer and procreation raise a host of novel legal issues involving the rights of those trying to create families after cancer treatment and any resulting children, as well as the responsibilities of those who assist them. Recent court decisions, although neither consistent nor plentiful, highlight the emerging legal issues for patients, providers, and offspring. This article explores a number of legal issues related to cancer and parenthood, including: 1) patients' cryopreservation of sperm, eggs, or embryos and subsequent access to and use by them or their former partners; 2) fertility preservation in minor patients; 3) posthumous reproduction and legal parentage issues for children born from cryopreserved embryos or gametes; 4) wrongful life or wrongful birth claims of children born following their parents' cancer treatments; 5) access to, and discrimination in, medical treatment or alternative family-building options; and 6) professional responsibility and liability for providers relating to the potential fertility impact of cancer treatment. The limited, evolving court decisions, through the application of legal principles such as negligence, malpractice, discrimination, and parentage principles, provide some guidance for patients, providers, and policymakers in approaching the unique challenges presented by fertility preservation in the context of cancer treatments.