So, another topic brought up by my time at the bioethics conference in Cleveland: oncofertility. I had often thought about this very idea, but didn’t realize there was a field, the name coined of 2006, addressing just this. Basically, it is what its name indicates–fertility options for persons with cancer. De facto, it addresses women’s fertility specifically though in the future it may include men’s fertility as well. Scientifically there is no reason it couldn’t address men’s fertility. Anyway, women with cancer who undergo chemotherapy or radiation treatments for cancer often become infertile as these treatments usually impede ovarian function. Not to mention, of course, that cancers of the reproductive organs can directly cause infertility.
Scientists at Northwestern University created an consortium in around 2005 to help study the efficacy of harvesting ovarian tissue before cancer treatment for cryopreservation and later retrieval and use by their owners. This brings up many ethical issues. The first one that comes to my mind is how ethical is it for surgeons to perform what I term “uninformed unilateral or bilateral oophorectomies” now that the technology exists to attempt cryopreservation through oncofertility. Many women, anecdotal evidence suggests, go in for a particular pelvic or abdominal surgery such as an appendectomy and awake to find that the surgeons removed one or both ovaries (oophorectomy). This may be morally justified if there is immediate peril for the patient by a condition or disease and the only possible solution is to immediately remove the ovary or ovaries. All to often, though, this is not the only option and many women lose ovaries for very poor reasons. One in particular seen more often in the past was the removal of a woman’s ovaries after she had finished bearing children (whether she had entered menopause or not) to prophylactically prevent ovarian cancer. Studies now show that a woman can actually develop ovarian cancer when she has no ovaries, due to the residual tissue that surrounded it when intact. In any event, is it ethical for women in these positions to not at least have been offered the option of later fertility especially if they have not had any children, are intent on having some in the future, and could produce enough healthy ovarian tissue for cryopreservation?
Another ethical issue that springs forth is that of pediatric oncofertility. At the conference I attended one researcher directly addressed this issue, though I greatly disagree with most of her conclusions. She argued that allowing parents, or even the child in question, to choose cryopreservation is unethical. Clearly it is unethical for the doctors to directly decide as that would be rather blatant paternalism. Various people in the session questioned her stating that they did not believe parents choosing cryopreservation for their child was dictating a child-bearing future to them, as the researcher had argued. The particular researcher strung together a rather loose argument, in my opinion, indicating that women in the United States are increasingly defined by their ability to birth children. Thus, cryopreservation (at the current time, she stated) unduly reinforces on the child that they are obligated to use the preserved tissue. I agreed with the audience members who contradicted her in saying that cryopreservation merely allowed the child to have the choice, that nothing in cryopreservation inherently pressed the child into unwillingly having babies. I would like to further add that I feel there is nothing wrong with women being defined by the ability to bear children, even though some women have no ability to and some women consciously choose not to have children. I believe that the ability to bear children can be expressed both in the positive and negative: having babies and not having babies. Neither is better or worse than the other. It is simply a fact: a fact that indicates we are female. If we had nothing that indicated we were female (as virtually everything “female” about the female body is designed in order to bear children) then what would be the point of delineating sexes in humans? Men and women would be identical. We delineate, to some degree, because we must in order to reproduce and survive as a race. Delineation based on sexual reproduction is essential to our existence. (This is not to say, of course, that it is not perfectly acceptable for some to appear and live as the opposite gender than they were born or to be gay or lesbian. I am merely saying that if everyone did that then humans would quickly dwindle away.) I digress.
A further ethical issue in the field of oncofertility is what rights the owner of the harvested ovarian tissue has over the tissue. In order to successfully enter into the oncofertility research (as there are no commercial means currently available for this method), a “donor” must be able to produce six strips of ovarian tissue measuring 2 by 10 millimeters. This amount of tissue must be recovered in order to continue. 80% of the tissue is retained for the “donor” to use at will, though she must pay for storage until such time she decides to use it or dispose of it. The other 20% is used by researchers to develop new techniques of retaining and restoring fertility. So, what if the “donor” decides after the harvesting that she does not want the 20% used for research? What is the ethical response? Legally, the researchers outright own the tissue so they have no obligation (other than perhaps a moral one) to follow these wishes. Also, what if research with the 20% reveals a viability problem that would apply to the 80%, such as a genetic defect? What obligation do the researchers have to inform the “donor” of such a defect? Currently, there is no legal standard indicating they must inform the “donor.”
There are many more ethical issues to be addressed within the field of oncofertility, but these are meant to present a starting point to understanding the complexity of the research being done. Ethical obstacles notwithstanding, I am enthusiastic about this new field and am encouraged that the field is now developing. It reminds me of another session I attended at the conference in which a scholar postulated that the narratives of cancer survivors are considered finished once the cancer has been eradicated. The development of oncofertility shows that a cancer survivor’s narrative is nowhere near complete when the cancer goes away. There is more life to live than just surviving cancer. Questions? Comments? Let’s talk about it!