Fertility to Futility: Treatment When Prognosis Is Very Poor, Or Worse
The great percentage of patients who present for fertility services have a chance of having a baby and their prognoses range from excellent to poor. Less commonly, the likelihood for success is very poor to almost zero. While most couples set limits (emotional, financial, age-related) to their treatments, others do not and find great difficulty in stopping treatment, even with a nearly nonexistent chance for success. In such scenarios where the patient desires to continue treatment despite overwhelming odds, the clinician faces an ethical dilemma in the continuation of care. When do the known risks, or even side effects, of the patient’s desired treatment(s) outweigh the benefits (the exceedingly small chance for a baby)? And, how are misunderstandings and disagreements between patients and physicians in these regards best handled? A recent journal article in Fertility and Sterility from the American Fertility Society’s Ethics Committee provides an opinion on fertility treatment when the prognosis is very poor or futile (https://doi.org/10.1016/j.fertnstert.2019.01.033).
Certainly, open communication between the patient and physician is essential for preventing and/or resolving conflict and patient education, according to the latest medical literature, as well as psychosocial examination of motives and values are important in the worst prognosis cases. Even so, there may be times when a patient insists on continuation of therapy, not willing to stop treatment or to consider alternative means for developing a family. The Ethics Committee recommends the development of patient-centric policies for each IVF center to enable clinicians to make the best, evidence-based decisions. There may be cases in which the clinician ethically refuses to provide further care. In addition, there may be rare occasions when provision of treatment in the futile case yields a psychological benefit; however, in most situations, therapy in futile cases cannot be justified medically or ethically. Every patient must be part of the dialogue of the informed consent process, with a clear discussion of the indications, risks, side effects, potential benefits, and treatment alternatives.