Ethics Rounds

Cross-border reproductive care is a term used for people who seek infertility treatment across jurisdictional borders or internationally. It is part of a larger, rapidly growing trend referred to in non-fertility settings as “medical tourism,” for everything from bariatric surgery to kidney transplants.

Why do individuals and couples seek fertility treatment away from home? According to the Mental Health Professional Group's Post-Graduate Course I attended at the October American Society for Reproductive Medicine annual meeting, people may travel because their local laws prohibit egg donors from being anonymous or from being paid. They may also be seeking to obtain services that are not offered in their own states or countries. Cost may also be a motivator. Americans travel to Thailand, the Ukraine and India, among many other countries — often for care that they cannot afford in the United States. Another large group is the “socially infertile” — singles and same-sex couples who want to become parents and may be prevented from receiving such services in their home countries.

Competency for global practice

What competencies do psychologists need to deal with this emerging trend? APA's Ethics Code requires that psychologists practice within the boundaries of their competence and “undertake ongoing efforts to develop and maintain their competence.” (Standard 2.03 — Maintaining Competence). According to Standard 2.01 (b): “Where scientific or professional knowledge in the discipline of psychology establishes that an understanding of factors associated with age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language or socioeconomic status is essential for effective implementation of their services or research, psychologists have or obtain the training, experience, consultation, or supervision necessary to ensure the competence of their services ....”

Psychologists who practice in the area of infertility are at the crossroads of crossborder reproduction. The mental health counseling they provide often supports clients through the reproductive process and helps them explore the implications of the treatment on their future families. These practitioners must have an understanding of the various psychological, family systems, medical, legal, cultural and technological issues, among others.

People who seek to build their families via reproductive medicine are often focused on the immediacy of the quest for a child. The well-trained psychologist may be one of the best professionals to point out possible issues the clients may need to explore further, such as whether the parent will be able to bring a child born of a gestational carrier back into the country of origin. Although the psychologist cannot be expected to have a deep knowledge of the laws of all countries or all medical techniques, he or she should be conversant in the basic parameters of common legal and medical issues that may arise. Although the psychologist cannot act as a physician, he or she may be called upon to help the patient begin to discuss the possible risks and benefits of various medical treatments. The psychologist may also help the patient begin to consider the child's future psychosocial needs, including issues surrounding identity formation and disclosure of the story of his or her origin.

Patients who seek out such care often use the Internet to find services worldwide. Several blogs chronicle people's attempts at “global” family building. Clinic and agency Web sites give patients information about the services they provide and market to specific audiences. Some clinics use Skype to enable clients to meet physicians, prospective gestational carriers and egg donors. The psychologist must be prepared to help the patient navigate through such a vast world of information and marketing materials. If the psychologist also uses technology to counsel or assess patients across state or country borders, he or she must also be aware of licensure and other practice issues that may arise.

Psychologists must also be culturally competent given the myriad possible cultures and ethnicities involved. A psychologist may, for example, need to explore the meaning of infertility in the patient's culture and the availability of other culturally acceptable avenues for family building. A psychologist may also help a client look at the impact assisted reproduction, adoption or remaining childless may have on family relationships. They may also need to help clients consider what their religions may say about various technologies and whether they intend to follow the religious guidance. Similarly, cultural authorities outside the immediate family may provide guidance to be followed or ignored. The psychologist will also need to consider the meaning and impact of any use of an interpreter for the counseling sessions. APA's Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change for Psychologists; Guidelines for Providers of Psychological Services to Ethnic, Linguistic, and Culturally Diverse Populations; and Guidelines for Psychotherapy with Lesbian, Gay, and Bisexual Clients, among other guidelines, may be relevant to the treatment depending upon the patient.

Psychologists' internal conflicts

APA Ethics Code Standard 3.06 (Conflict of Interest) requires psychologists to refrain from taking on a professional role when their personal interests or relationships could reasonably be expected to impair their objectivity, competence or effectiveness in performing their functions as psychologists, or expose the person involved to harm or exploitation.

This standard raises the issue of how the psychologist's own values and beliefs may affect his or her work. What are areas of possible personal conflict for psychologists working at this global crossroads? Personal beliefs about the importance of disclosure of origins to the children born from the travels, or feelings related to the individual “sidestepping” home country restrictions may make a psychologist uncomfortable. A psychologist may be disturbed by the recognition that certain reproductive medical care abroad carries a greater risk of multiples and the cost of care for those children will fall on the home country's health system.

Finally, the psychologist may struggle with whether the use of Third-World egg donors or gestational carriers exploits women or, alternatively, reflects a progressive societal valuation of these services and provides important new sources of income for their families. As long as these feelings do not rise to the level of grave moral concerns that reasonably would be considered to render the psychologist not objective, competent or effective or expose the patient to harm or exploitation, a psychologist should not be disqualified from providing these services.

The ethical issues faced by psychologists who work in the area of cross-border reproductive care are similar to issues that may arise in medical tourism more generally. The medical tourism trend is likely to continue to grow as the Internet makes geographically restricted medical care a thing of the past. The stimulating Mental Health Professional Group post-graduate course allowed me to begin to consider the ethical issues that arise for psychologists in this “global” work.

Lindsay Childress-Beatty, JD, PhD, is deputy director of APA's Ethics Office.

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