Why our ethics demand canceling in vitro fertilization - for now
Extraordinary times call for extraordinary measures. Recent directives to cancel elective surgeries and procedures will place significant burdens on patients and health care professionals. But these rationing efforts are ethically necessary to preserve our short supplies of PPE and other essentials.
Louise P King, M.D., J.D.
Director of Reproductive Bioethics
Harvard Medical School
Recently, the Surgeon General advised to postpone elective surgical procedures whenever possible. The American College of Surgeons issued a strong statement in support encouraging surgeons to “plan to minimize, postpone, or cancel at this time.” (https://www.facs.org/about-acs/covid-19/information-for-surgeons) The American College of Obstetricians and Gynecologists, the American Association of Gynecologic Laparoscopists, American Society for Reproductive Medicine, the American Urogynecologic Society, the Society of Family Planning, the Society of Gynecologic Surgeons, the Society for Maternal-Fetal Medicine, and the Society of Gynecologic Oncology all followed suit. (https://www.acog.org/news/news-releases/2020/03/joint-statement-on-elective-surgeries)
The recommendation to hold all non-urgent surgical cases is a reasonable and ethical rationing response. It is not simply the OR space and personnel but also equipment and specifically gowns and masks that need to be conserved. Our essential personnel are currently restricting to 1 mask per day and in some cases trying to make their own PPE from various scraps severely impacts their ability to safely care for patients. This shortage is presenting well ahead of others that are predicted including shortage of antibiotics, blood and anesthetics - all of which could potentially be used during elective cases or if complications occur. Whether your current area is affected or not at the moment, your use of these resources affects the country's supply as a whole.
The reasoning above applies equally to invasive procedures including IVF. (https://www.sart.org/news-and-publications/news-and-research/press-releases-and-bulletins/asrm-issues-new-guidance-on-fertility-care-during-covid-19-pandemiccalls-for-suspension-of-most-treatments/) Any procedure that uses our scarce resources during these crucial moments is a burden we simply can’t afford as a nation. Moreover, any non urgent contact with patients in the context of a 30% asymptomatic rate and lack of adequate rapid screening is not mindful of our need to socially distance and flatten the curve.
Of course cancelling procedures will be exceptionally difficult. The decision to cancel procedures or surgeries is a burden to patients who have been waiting months In some instances and must continue to wait. (https://www.theatlantic.com/science/archive/2020/03/patients-whose-surgeries-are-canceled-because-coronavirus/608176/) It is a severe burden financially to private and public programs large and small. But, it is still necessary and ethically required. Labor law attorneys are well versed in legal remedies to help businesses and their employees in times of crisis. State and federal programs offer assistance and more are being announced each day. Massachusetts' governor has issued a law requiring insurers to reimburse for telemedicine visits. If this is not available in your state you should bombard your governor with letters demanding they to do the same.
The claim that these efforts to preserve important resources both by cancelling non urgent procedures and flattering the curve are “herd mentality” is belied by the situations in Italy, Spain and Iran. We will not regret over-reacting if we can avoid what they are facing. That said, given the burden these measures put on patients and providers, any decision to hold IVF should be periodically and frequently revisited. The situation is changing rapidly. If we are able to address shortages and flatten the curve we can reconsider these decisions.
At the very least, think of your ER and hospitalist colleagues. A leader in hospital medicine in Italy recently died and officials in Italy have hypothesized that his death was related in part to a lack of protective equipment. (https://www.euronews.com/2020/03/18/italian-doctor-dies-of-coronavirus-after-working-without-gloves-due-to-shortage)Even if only a fraction of our population becomes infected, a very large number will need hospital care and we currently have only enough PPE for less than one week. You should defer elective procedures with this in mind if nothing else.