An enjoyable aspect of my job is that I am able to learn in more depth about the various ethical issues facing psychologists in the course of their daily work. It is invaluable to me as deputy director of APA's Ethics Office to understand ethical issues such as competence, informed consent and conflicts of interest in that context. In November, I had the pleasure of attending the American Society for Reproductive Medicine's 64th Annual Meeting in San Francisco: "Bridge to the Future of Reproductive Medicine." I was struck by the wide range of health and mental health professionals who were members of an association "devoted to advancing knowledge and expertise in reproductive medicine, including infertility, menopause, contraception and sexuality."
One of the strongest professional groups involved in ASRM is the Mental Health Professional Group (MHPG), whose members are psychologists and others interested in the MHPG's mission "to promote scientific understanding of the psychological, social and emotional perspectives of infertility patients." What most impressed me is that psychologists are involved in all aspects of human reproduction. It was quickly apparent that psychologists' work in this area involves an abundance of roles, clients and different settings, including private practice, employment in hospitals and IVF clinics, and consultation. Clients include men and women, heterosexual, gay and lesbian couples, single parents and institutional clients.
Psychologists counsel "intended parents" who are considering using egg or sperm donation alone or in combination with the services of a woman who will carry and give birth to the baby for them, a "gestational carrier." They consult with IVF clinics or private agencies to conduct psychological screening of prospective egg donors or gestational carriers. They lead medical staff trainings around psychological issues in infertility and provide group training with individuals and couples in mind-body aspects of coping. Psychologists conduct research on the psychological aspects of reproduction. Psychologists also provide counseling regarding sexual health, pregnancy and parenting issues after infertility and after infant loss. Many psychologists also work with couples considering adoption or child-free living.
A deep well of knowledge
As I attended the extensive MHPG programming, I was struck by the number and depth of the competencies that a psychologist working in this area must master. To help clients understand and navigate medical systems and make informed decisions about their care, psychologists must understand rapidly changing medical treatments and technologies. Competence in psychological testing is required when screening for participation as a gestational carrier or egg donor. Knowledge of family systems and relationships are also important competencies. The psychologist may be called upon to help all those involved in decision-making to consider the possible impact of decisions on their future families and offspring.
In addition, the psychologist's work occurs within an environment where complex bioethical decisions must be made on an on-going basis as new technologies are developed and research sheds new light on the ways current technologies affect the psychological health and well-being of families. Many profound issues arise, such as intergenerational family members as egg or sperm donors, selective reduction of embryos in multiple gestation pregnancies, and the disposition of surplus frozen embryos, that require added cultural and religious competencies when working with patients.
Before the annual meeting, the MHPG has two all-day post-graduate courses on topics relevant to mental health. One of these courses "Assisted Reproduction for Gay Men and Lesbians: Social, Psychological and Legal Aspects" involved presentations concerning the psychological research on gay and lesbian parenting, legal issues, and issues in counseling, including APA's "Guidelines for Psychotherapy with Lesbian, Gay, and Bisexual Clients." The day ended with a panel of gay fathers who told their stories about building families. As I listened to the men speak of post-pregnancy relationships they had developed with the egg donor, gestational carrier, or biological mother, I was struck by how innovations in reproductive technology result in fluidity in our concept of family.
Informed consent regarding donation also arose in various sessions. Unlike sperm donation, informed consent of egg donors takes place in the context of a formal psychological screening process in which psychologists play a significant role. While the contrast between genders may reflect differences such as level of medical risk, I pondered whether the lack of a screening for sperm donors minimized the psychological complexity of sperm donation and reflected outdated beliefs regarding procreation and gender.
Throughout the sessions, I heard numerous interesting discussions concerning how one obtains informed consent of donors of both genders who are often young, unmarried and without children, given the shifting perspectives that marriage, parenthood and children may bring for both men and women. I also considered whether psychologists, in screening of egg donors, are also setting the stage for better informed consent by helping women to understand and explore these shifting perspectives. It appeared to me that often the psychologist is the professional best able to consider whether the donor's decision to donate has been fully explored given the conflicts of interest inherent in the financial incentives of the clinic or agency, or the personal relationships between intended parents and the "known donor."
Psychologists involved in counseling intended parents concerning their disclosure to the donor-conceived offspring must also help parents explore the future impact of their disclosure decisions on children not yet born and families not yet completed. Issues involving disclosure of the donor's identity must also be determined prior to donation so that informed consent of the donor can occur. Given the advances in DNA testing and the wealth of information available on the Internet, the question arises whether donors or intended parents can be assured that any particular donation will remain anonymous.
The personal and the professional
The conference also gave me an opportunity to ponder the impact of personal experience on professional practice. Indeed, I was awed to meet so many pioneering individuals who had, in part, been drawn to infertility work due to the lack of mental health resources during many of their own family-building journeys. The APA Ethics Code reflects the understanding that there is a relationship between our personal and professional lives. To what extent do personal experiences inform and indeed strengthen an understanding of, and connection with, patients? At what point do personal experiences become a detriment to good clinical care if the therapist does not remain vigilant concerning the effect of personal values and experiences on practice? I was impressed by the extent to which MHPG members remain alert to the effect of their private infertility experiences and outcomes, as well as their personal values, on their work.
This opportunity to see a growing practice area for psychologists up close was invaluable for the education of the Ethics Office. Attending the MHPG programming increased my ability to be a resource for psychologists struggling with ethical issues in the context of health psychology in general and an infertility practice in particular. It is my hope that a greater understanding on the part of the Ethics Office is the reward to the members of the MHPG for graciously permitting me a window into their work.
Lindsay Childress-Beatty, JD, PhD, is deputy director of APA's Ethics Office. Comments on Ethics Rounds can be sent to Ethics.