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The Point - November 2013

In this edition:

Article #1
Excerpted from “Rise in IVF popularity leaves thousands of babies in limbo,” World Magazine. October 25, 2013 -- More women are using donated eggs for in vitro fertilization (IVF) and more healthy babies are being born through the process, according to a study released in October. While this is good news, the process also creates more embryos than can be implanted, leaving hundreds of thousands of frozen embryos in fertility clinics. For women with viable eggs who cannot become pregnant, IVF involves extracting their own eggs, fertilizing them and then re-implanting them in the uterus. Women who do not have viable eggs go through a similar IVF process using eggs from other women. The number of women who attempted IVF from another woman’s eggs increased from 10,801 in 2000 to 18,306 in 2010. The percentage of healthy outcomes from donated eggs, defined as a baby born after 37 weeks weighing 5.5 pounds or more, increased from 18.5 percent in 2000 to 24.4 percent in 2010.

The study also found that women are increasingly implanting only one embryo in an IVF cycle. Because doctors are unable to predict with certainty which embryos have the best chance of resulting in a healthy baby, many women implant more than one embryo during an IVF cycle, increasing the odds that at least one of the embryos will survive. However, between 2000 and 2010, the percentage of women who transferred only one embryo, and thereby avoided the possibility of multiple births, increased from less than 1 percent to 15 percent.

However, the process is wrought with ethical controversy, as many clients don’t know what to do with the extra embryos created: An estimated 600,000 frozen embryos are stored in fertility clinics throughout the United States. “The vast majority of people don’t have a plan,” says Daniel Nehrbass, executive director of Nightlight Christian Adoptions, an organization that does embryo adoptions. “They don’t want to destroy them because there is finality to that. So they store them and the years go by.” In the face of many grey ethical issues, including the question of whether couples should pursue IVF at all, Nehrbass said NightLight sees two things as black and white: “Embryos are human life, and they deserve a chance to be born.”

Commentary #1
Medical Director for the National Embryo Donation Center Jeffrey Keenan, MD: “Currently there are more than 600,000 cryopreserved embryos in liquid nitrogen tanks in U.S. fertility clinics alone. Although some 80 percent of couples say that they plan to use these for future reproduction, the reality is that a large percentage of these will never be thawed and replaced in the genetic mother’s uterus. Because cryopreservation has only been performed for about 25 years, no one really knows what the ultimate fate of these embryos will be. It is possible that many will eventually be destroyed, donated to destructive and unfruitful embryonic stem cell research or even left as a sort of ‘inheritance’ for the children (genetic siblings).

“What created this problem is the marked improvement in IVF success rates, an increase in the number of procedures and the more prevalent use of donor eggs as noted in this article (donors generally produce more eggs of better quality with higher pregnancy rates). At the same time, most clinics have not changed their practices which typically involved inseminating ALL eggs regardless of the number or likelihood that there will be additional embryos remaining long after the couple has completed their family building plans.

“Unfortunately, the American College of Obstetrics and Gynecology and other professional bodies do not even consider an embryo a viable being until it has implanted in the uterus. This view has at least contributed to the almost complete disregard for the lives of embryos by most members of our profession.

“The National Embryo Donation Center was founded with the assistance of the CMDA and performed its first embryo transfers in 2003. So far, more than 400 children have been born or are awaiting birth as a result of the NEDC’s efforts, making it the largest and most successful provider of embryo donation/adoption services in the world. The NEDC advocates limiting the number of eggs inseminated with each IVF cycle, as well as increasing the excellent alternative of freezing eggs rather than embryos. NEDC is currently seeking affiliates in multiple cities around the country to perform adoptive embryo transfers.”

Article #2
Excerpted from “Therapists Explore Dropping Solo Practices to Join Groups,” Shots: Health News from NPR. October 24, 2013 -- In the corporate world of American healthcare, psychologists and other mental health therapists are still mostly mom-and-pop shops. But the business model for therapists is shifting away from solo practices and toward large medical groups, say mental health experts. That change is propelled by the Affordable Care Act, which mandates mental health benefits in insurance coverage, and by the Mental Health Parity Law, which requires private and public insurers to cover mental health needs at the same level as medical conditions — by charging similar copays, for example.

Organizations that advocate for mental and behavioral health — groups that long complained that they were treated as second-class providers — have applauded the federal laws. But inclusion has come with some unhappy caveats, including less pay and more paperwork. Patients used to paying $150 in cash for a therapy session will, with some limitations, have sessions covered by their health plan. That means many therapists will have to figure out innumerable insurance plans and byzantine billing codes for the first time.

In many ways, therapists are encountering what medical doctors have complained about for years: the confusing, confounding and, some might say, hostile insurance bureaucracy that providers must tangle with in order to get paid. The increasing complexity of running a practice has meant more therapists are taking down their shingles or forming groups with other therapists to share the burden, executives at national mental health groups say. Others have joined large medical groups that offer mental health services as part of comprehensive care.

Commentary #2
CMDA Member and Psychiatrist Robert Rogan, DO, JD: “This article touches on several current issues in mental health affecting our society. One, the loss of autonomy, may be far more serious than we realize. The freedom to serve as we in conscience believe best is something we need as believing practitioners. Conscience issues are already prominent in current medical practice in general. If we can’t ‘choose our clients,’ we may find ourselves being asked to provide therapy in an area we find morally uncomfortable.

“People do seek mental health services and pay ‘out of pocket’ not just for insurance reasons but also for privacy. The HIPAA regulations with compliance that began on September 23, 2013 seem to reflect this possibility.

“Paperwork issues are not just documentation chores but very concerning potential legal traps. Billing is serious business for more than just reimbursement reasons. We need to be truthful but careful in what we write. Also, we need to be ultra-careful what we sign. We need to know every pitfall in contracts we sign. If there is legal terminology you don’t know, look it up or get legal counsel. A subtle term like ‘hold harmless,’ now in very common use, can be the entrance to a professional minefield.

“On the other side, solo practice can have physical dangers with our changing patient demographics. Group practice can provide more collegiality as ‘iron sharpens iron.’ We can be of great use in practices where mental health service is needed by other non-mental health practitioners.”

Article #3
Excerpted from “Ethical dilemmas surround those willing to sell, buy kidneys on black market,” CBS News. November 1, 2013 -- Government estimates show 18 people die each day waiting for a transplant, and every 10 minutes someone is added to the transplant list. The need for kidneys is especially high. As of October 25, 98,463 people were waiting for a new kidney in the U.S., the most requested organ by far. Thus far this year, only 9,708 kidney transplants have been completed.

The beauty of kidney donation compared to other organs is that people are born with two of them, making possible donation from a living person. But, the fact that people can live a normal life with one kidney has helped the black market kidney trade flourish.

Some argue that if the donor is made aware of all the potential risks and still consents, he or she should be free to sell a kidney. Advocates say if people are able to sell other body parts like hair or eggs, they should be allowed to get money for their organs. And recent research suggests paying for organs could reduce societal healthcare costs long-term. An Oct. study showed that if people were able to pay $10,000 for a living kidney donation, medical costs -- such as related to dialysis treatments -- would go down overall and patients would get additional quality years of life compared to the current system. However, the practice of getting paid for an organ is illegal everywhere except Iran.

Caplan believes that the current opt-in system of organ donations should be changed to an opt-out. Now, Americans select on their driver's licenses if they'd like to donate their organs, but they're calling for a system where everyone by default is a donor. The bioethicist noted that data show that most people are willing to be an organ donor, so the system should be changed, so the few who are against it can have their decision respected.

Commentary #3
Trauma Surgeon and CMDA Member Christine Toevs, MD: -- “This article touches on many of the current ethical issues related to organ procurement. The position offered by the organ procurement organizations (OPO) is as follows: organ transplantation is good and many people are waiting for organs; therefore, anything that increases organ donation is inherently good.

“The main solution provided to increase organ donation is to pay for organs; if we pay for organs, more will donate and we will save more lives. The problem with this argument is that studies have shown that paying for organs exploits the poor and very little of that money actually reaches the organ donor, most taken by brokers and middlemen. Since most of the organ donors would likely be poor, the risk of coercion and lack of informed consent increases. The aging of the population has resulted in an increase in chronic renal disease, and this increases the long-term potential health issues of the organ donor. When their kidneys fail, do they now go to the top of the recipient list? Who takes care of the organ donor and their complications when, which although rare, do occur?

“The OPOs have consistently demonstrated a lack of informed consent at any step of organ donation (is checking the box on your driver’s license really informed consent?). It is unlikely that even regulated markets for selling of organs will result in safer protections for the organ donors. People are not commodities with extra superfluous organs that should automatically go to others. There is great need for organs, but that need doesn’t allow for exploitation of others.”

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