Infertility: Interventions for Shame, Mourning, and Feelings of Inferiority

Background
The reader will no doubt be aware of the many public debates surrounding fertility treatment. Most newspapers carry stories about Single parents receiving donor sperm, second families for those already grandparents, multiple births, surrogacy that goes wrong etc. There are also the debates in other media about interference with the course of nature, a woman's right to a child, the disposal of fetal material, creating embryos that might be used for research fetal reduction, sex selection and the availability of free treatment and postcode lotteries.

This outline is not exhaustive. All involve some reference back to the value systems of the writers or the organizations they work for. And they demonstrate the wide variety of values, opinions and ethical stances within our society -- few are deemed 'wrong' unilaterally.

The therapist and the licensed clinic
The therapist offering a service to a licensed clinic (and I am limiting this article to those practitioners) faces even more dilemmas at work. Most of the staff s/he deals with will have their own opinion on the issues, and the clients then bring their own view. The therapist works against a complicated tapestry -- one that is being regularly unstitched, rewoven or repaired. These alterations are necessary because of changes in the law and regulation, both national and European, advances in science and reproductive technology and the changing face of the society in which we live. For example, the code of practice for licensed clinics introduced in 1991 has reached its sixth edition, regulations about the welfare of the child have changed, the law on anonymous gamete donation has changed, the European courts have ruled on the disposal and storage of human tissue and embryos and the right to a family life, egg freezing has happened, cloning is possible, single parenthood and civil partnerships for same-sex couples is enshrined in law. All this has happened in the last 15 years. All have raised ethical issues.

Few medical settings have quite such a range of issues and rate of change, although I do not want to detract from any other work in medical settings. However I believe that, once in the counseling room, adherence to the Counseling Board's Ethical Framework is the leveling factor in our work with clients. We may take part in the wider debate but it should not affect the client's autonomy.

In some licensed clinics the person delivering the counseling may adhere to a different set of ethical guidelines from those of Counseling Board. The code of practice allows others -- for instance, social workers and psychologists -- to deliver counseling. For them, the primary ethical principle may not be autonomy but may, for example, be beneficence or fidelity. If there are a variety of ethical stances amongst therapists this can lead to sources of stress and the need for respect for the position of others on such matters as disclosure of information and the educative function of the counseling input.

Therapy offered to the clients of licensed clinics can also be offered from a number of different bases. The therapist may be a full member of staff with obligations to their employer and bound by the policies of that clinic. This can throw up ethical dilemmas. They may have practicing privileges for their independent practice at the premises of the clinic but be bound by the additional requirements of the Health Care Commission for such privileges. This too can impinge on the therapist on such matters as note keeping and child protection, and threaten autonomy or confidentiality. The therapist can be a person in a private practice with links to the clinic that can range from loose to close depending on the nature of the contract for service.

So there are many ethical issues a therapist working in this setting has to address. It highlights the enormous importance of good supervision and consultation, along with ethical decision making.

Current ethical issues for counselors
* Who is the client?
This debate has lasted since artificial reproductive technology became available. Is it the person, the couple, existing children or the child who may be born?

I will briefly consider the child who might be born. We are now at a time when there can be input to the debate from those children born since 1979 and there is information from longitudinal studies on the welfare and progress of these children. It is my view that this may inform those seeking 'implications counseling' (where clients reflect upon and understand the implications for themselves and others of the procedures they propose to undertake, exploring the personal meaning as well as the legal, ethical, social and psychological issues) but that if the counselor interferes with the decision making of the client this is contrary to the principle of autonomy. However, there are counselors who feel that a directive approach is required, for example advising, requiring or educating people on a need to inform children of their genetic origins.

The question has been thrown into relief by the abolition of anonymous gamete donation since April 2005. This was informed by advances in medicine that make DNA testing more accessible, by treatments that work with genetic material, by a culture that is making information and records more available and by those who recognize a benefit from avoiding secrets in people's lives about identity, and the positive gains from knowing and having access to one's complete identity.

Is the client also the clinic and the wider clinical team? This raises a question about how involved the counselor should be in decisions on treatment, entries in patient notes or general feedback. It may be that information comes out about issues in someone's past e.g. about child rearing or illness. Should this be made available to the team or could it be that disclosure is contrary to the principle of fidelity and may also preclude therapeutic work which may bring the person to a place where treatment could be available and thus does not honor the ethical principle of justice. In the light of this, it is my view that the counselor should not be involved in these areas. The BACP Ethical Framework is extremely useful in helping practitioners to manage this and I refer to the section on Working with colleagues. The HFEA code of practice is also clear that counseling is confidential and notes must be kept separately from clinical notes and not be part of assessment.

However, many other people working in clinics have a role where they use counseling skills and have a different contract of confidentiality, for example confidentiality within the clinical team. It is here that I think the clinic and its staff are in some way in the client role. The counselor has a duty to explain difference of role and to ensure that they provide a service that others are confident to make a referral to and to understand when referrals are relevant. Once again, the section in the Ethical Framework on Working with colleagues is invaluable.

* The role in assessment
Some counselors have been put in a position where they are seen as the assessor. It is understandably frustrating that the team views a member as possibly best placed to help make informed decisions on the welfare of a child or the strength of a partnership. However, the code of practice is quite clear that the role of the counselor is not one of assessment unless sharing information in line with professional guidelines. I do not believe that BACP's ethical guidelines would support a role in assessment unless there was a situation where the client posed a risk of causing serious harm to themselves or others. But I believe it is possible for some people who offer counseling also to use their skills in assessment as long as the contract with the client is quite clear that this is not a counseling contract and that if counseling issues arise they will be dealt with separately.

* The voluntary nature of the contract
The HFEA is quite clear that counseling is a voluntary activity but if a person does not take up the offer then this can be taken into consideration on treatment decisions. Hardly voluntary? This is not an issue that affects only counseling and infertility. But if information on and adherence to the ethical principles is clear to clients before an appointment many of the barriers can be overcome and trust and the principle of fidelity achieved.

* Boundaries
Treatment often involves a number of people to create a family. This covers egg and sperm donation by known and unknown donors, surrogacy arrangements and egg sharing. How far is it advisable or feasible to see people separately or to have separate counselors for all parties? Fortunately there is now a network of counselors who can help, and those working on their own can call in another counselor if the need arises and boundary issues are a problem. In making the decision, all the ethical principles are called into the equation. I make particular reference to beneficence and for the requirement for supervision. A supervisor who knows the counselor, their limitations and strengths and the setting with its pitfalls and regulatory requirements is a huge benefit. They can provide the professional support needed to make a decision and challenge the counselor, should they think they are making an unwise decision or do not have the skills or knowledge to manage the situation.

* Informed consent
There are a number of scenarios that can arise. For example, does a sister feel under pressure to help her sister, or a daughter to donate eggs to her mother, or a friend to carry a friend's child? Can the young woman or couple with limited or no English understand the procedures? Is the interpreter massaging the information? Keeping trust and offering a trusted interpreter and time are all important but not always easily available, particularly when budgets are restricted. Once again, the ability to work with the setting to explain good professional practice and find resources to provide it is important.
-Baron, Judith; Counseling and Infertility: Ethical Issues; Therapy Today; Oct 2006; Vol. 17; Issue 8.

Personal Reflection Exercise #8
The preceding section contained information about ethical considerations for the therapist. Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 22
What are ethical dilemmas an infertility therapist may face? Record the letter of the correct answer the CEU Answer Booklet.