title: Determining access to assisted reproductive technology: reactions of clinic directors to ethically complex case scenarios.
abstract: BACKGROUND
  Our aim was to increase understanding of how patient selection is handled by assisted reproductive technology (ART) clinicians.
  
  
  METHODS
  Ethically complex case scenarios were evaluated by the directors of USA ART clinics. Scenarios included using a son as sperm donor for his father, sex selection without associated disease, treatment of morally irresponsible couples, and a dispute over embryo disposition. Respondents reviewed eight scenarios and gave their opinions on whether to offer treatment. Reasons given for these decisions were placed into one of 13 categories.
  
  
  RESULTS
  Survey response rate was 57%. Between 3 and 50% of respondents would treat in each case. Of reasons given, 'conditional' responses (requiring counselling, blood tests or agreement to other 'conditions') were common (31.4%). Non-maleficence (risk) accounted for 29.4% of responses, philosophy of medicine 18.9%, respect for patient autonomy 5.9% and legal concerns 4.6%. Discrimination and threats were each significant in one case. Reasons evoking absolutist beliefs, personal discomfort, commitment to justice, religion and ethical relativism were rare.
  
  
  CONCLUSIONS
  Clinicians felt conflict between a desire to respect patient autonomy and their discomfort over the risk associated with the procedure. They raised concerns about misuse of medical technology. Attempts to resolve complex issues through negotiation and compromise were common.
authors.affiliation: Department of Ob/Gyn Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756, USA. judy.e.stern@dartmouth.edu
authors.forename: J E
authors.initials: JE
authors.lastname: Stern
authors.forename: C P
authors.initials: CP
authors.lastname: Cramer
authors.forename: R M
authors.initials: RM
authors.lastname: Green
authors.forename: A
authors.initials: A
authors.lastname: Garrod
authors.forename: K O
authors.initials: KO
authors.lastname: DeVries
mesh_terms: D000028:Abortion, Induced; D000328:Adult; D001291:Attitude of Health Personnel; D015925:Cryopreservation; D004243:Divorce; D019924:Embryo Disposition / Q000941:ethics; D004622:Embryo, Mammalian; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009679:Nuclear Family; D018579:Patient Selection / Q000941:ethics*; D010820:Physicians; D011247:Pregnancy; D018607:Pregnancy Reduction, Multifetal; D011272:Pregnancy, Multiple; D019836:Preimplantation Diagnosis; D027724:Reproductive Techniques, Assisted / Q000941:ethics*; D012307:Risk Factors; D012743:Sex Preselection / Q000941:ethics; D013533:Gestational Carriers; D011795:Surveys and Questionnaires; D014019:Tissue Donors / Q000941:ethics; D014754:Violence