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Cross-border reproductive care in Europe

26 August 2008
By Professor Guido Pennings
former co-ordinator of the ESHRE Task force on Ethics and Law, Ghent University, Belgium
Appeared in BioNews 472
The European Society for Human Reproduction and Embryology (ESHRE) has been concerned about the development of cross-border infertility treatment for some time. There are three reasons for this: the frequently negative publicity for infertility treatment presented as 'reproductive tourism', the increasing numbers and the risks for patients. ESHRE has taken two steps to address these concerns: the creation of a special Task force on cross-border infertility care which intends to collect data, since at present no reliable data on the numbers and motives of people going abroad are available. Secondly, the Task force on Ethics and Law has issued a document on the ethical aspects. Two important factors determine the extent of the search for cross-border fertility care: restrictive legislation and limited access. A number of European countries have adopted restrictive legislation regarding infertility treatment. People who do not share the moral convictions underlying these laws, attempt to realise their wish for a child by looking for a clinic across the border. Secondly, access to treatment is limited in many countries because of insufficient provision (lack of clinics, qualified personnel and/or gamete donors) or because of financial considerations. When people have to pay for treatment out of their own pocket, or are confronted with long waiting lists, it is not surprising that they look for a cheaper and speedier provider elsewhere.

In early July, the European Commission issued a proposal for a directive of the European Parliament and of the Council on the application of patients' rights in cross-border health care. The main goals of this initiative are to give a clear framework for the provision of cross-border healthcare within the EU, to clarify the right to reimbursement for care provided abroad, and to ensure high-quality, safe and efficient healthcare everywhere in Europe. The European Commission hereby follows a recommendation of the Task force to extend the portability of health insurance for reproductive healthcare. However, one important preliminary point should be emphasized: we insist on the right of people to receive treatment at home. When people in a country on a large scale and for a long time lack access to affordable infertility treatment, this shows a structural deficit that has to be addressed by policy measures. The problems in the UK with NHS-provided IVF treatment illustrate this point. Only when a country fails to fulfil its obligation to guarantee basic services at home in time and for a reasonable fee, is it to the citizens' advantage to have the option to look for a clinic abroad.

The Task force on Ethics and Law considered some ethical aspects that are frequently ignored, such as the possible contributions of patient organisations and the obligations of the different doctors involved. Since crossing borders to receive treatment also holds a number of risks for the patients, it is argued that individual doctors, patient organisations, and professional medical societies should all contribute to improve the safety of the patients. One step has already been taken by the International Consumer Support for Infertility (iCSi), an alliance of infertility patient organizations, by launching a factsheet containing the medical, financial, legal and emotional issues to consider when seeking treatment abroad. The Task Force specifically looked at the obligations of the physicians involved. The first point concerns the duty of the doctor to refer the patients to a clinic abroad. Although the general duty to refer patients is recognized, the situation is complicated by the possible conscientious objection of the doctor and a possible legal prohibition to refer patients abroad for a treatment not allowed in the home country. Secondly, the referring physician has a partial responsibility for the patient he or she refers, especially regarding the provision of information and counselling. In addition, we believe that he or she should make an effort to collect information about the quality of the treatment patients receive abroad in order to select future references. Finally, the practice of fee-splitting is condemned as being against the best interests of the patients.

One of the main recommendations of the Task force is the organisation of systems of control and verification. A system of verification should be introduced in order to guarantee that all patients obtain safe and effective treatment wherever they go. Such systems are the responsibility of the governments but in the transition period a professional organization like ESHRE can take steps in the right direction by certification of clinics that meet the standards of good clinical practice.

G. Pennings, G. de Wert, F. Shenfield, J. Cohen, B. Tarlatzis and P. Devroey (2008) ESHRE Task Force on Ethics and Law 15: Cross-border reproductive care, Human Reproduction doi:10.1093/humrep/den184
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