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An Ethical Analysis of Assisted Reproduction Providers’ Websites in Pakistan

Published online by Cambridge University Press:  27 June 2016

AYESHA IRSHAD  and
GABRIELE WERNER-FELMAYER
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Abstract:

Assisted reproductive technologies (ARTs) and reproductive genetic technologies (RGTs) are intertwined and coevolving. These technologies are increasingly used to fulfill socially and culturally framed requests, for example, “family balancing,” or to enable postmenopausal women or homosexual couples to have genetically linked children. The areas of ART and RGT are replete with ethical issues, because different social practices and legal regulations, as well as economic inequalities within and among countries, create vulnerable groups and, therefore, the potential for exploitation. This article provides an overview of the ART and RGT landscape in Pakistan and analyzes the available online content addressing Pakistani citizens and international clients. We explored the topic in view of socioeconomic challenges in Pakistan, particularly deeply rooted poverty, lack of education, gender discrimination, and absence of regulation. As online information given by ART and RGT providers is readily available and could easily raise false hopes, make use of discriminatory statements with regard to women, and promote gender selection to meet sociocultural expectations, it should be subjected to quality control.

Keywords

Pakistanreproductive clinicsassisted reproductive technologies (ARTs)reproductive genetic technologies (RGTs)

Information

Type
Special Section: Bioethics Beyond Borders
Information
Cambridge Quarterly of Healthcare Ethics , Volume 25 , Issue 3 , July 2016 , pp. 497 - 504
Copyright
Copyright © Cambridge University Press 2016 

Introduction

Since the birth of Louise Brown in 1978, the field of assisted reproductive technology (ART) has been challenging ethics, morality, and religion.Footnote 1 This debate has intensified during recent years due to the rapidly coevolving field of reproductive genetic technology (RGT) and the fact that assisted reproduction is increasingly used to fulfill social rather than medical needs.Footnote 2 In the study described in this article, we examined the situation of assisted reproduction in Pakistan, as some of its socioeconomic and cultural characteristics carry exploitative potential.

Pakistan is an Islamic state by constitution. The majority of its Muslim population belongs to the Sunni sect of Islam (96.28% of Pakistanis are Muslim, 85–90% are Sunni, and 10–15% are Shia; other groups include Ahmadis, Christians, and Hindus and make up 3.72% of the population).Footnote 3 In Pakistan, ART was introduced during the late 1980s. Although Islamic ethical considerations limit use of the technology to married couples,Footnote 4 there is no regulation or oversight by health authorities, and legislation and debates are lacking. Moreover, official sources such as the Pakistan Bureau of Statistics or the Pakistan Medical and Dental Council (PMDC) do not provide statistics on ART centers and their offered spectrum of procedures (according to representatives of both organizations, personal communication). The general population’s level of knowledge and awareness about the ethical, legal, and religious aspects of ART and RGT is not known, but it can reasonably be assumed to be low due to the high prevalence of illiteracy.

Methodology

In order to better understand the current practices and services of ART and RGT in Pakistan, between July 1 and September 1, 2014, we performed a web content analysis by reviewing the websites of ART providers in Pakistan. As no ART clinic registry is available in the country, we used the Google search engine as a tool to find ART/in vitro fertilization (IVF) clinics in Pakistan. The keywords used were “IVF in Pakistan,” “sex selection in Pakistan,” and “IVF in [city name: Lahore, Islamabad, Karachi, etc.].” We also found links to certain chat domains, such as Yahoo! Answers, where the users were discussing preferred IVF clinics in Pakistan. The names of ART providers from these conversations were used as keywords to find the websites. The search engine also provided direct links to ART providers’ websites. We devised an exploratory key consisting of location, landing page statements, ethical standards, quality certification, highlighted services for prenatal sex selection, foreign affiliations, calls for financial donations, social media accounts with online brochures and pictures, and success rates of the center.

We also examined the information provided by the websites with reference to the guidelines of the PMDC 2001 Code of Ethics and advertisement guidelines for physicians. The PMDC is the statutory regulatory and registration authority of medical and dental education for medical practitioners in Pakistan.Footnote 5 According to the revised PMDC 2001 Code of Ethics, practitioners are expected to fulfill the ethical principles of autonomy, beneficence, nonmaleficence, and justice. The code also provides guidelines to physicians regarding advertisement. According to these guidelines, physicians are not allowed to exploit patients’ vulnerability or to make claims about the quality of the service. Also, physicians must not put pressure on people to use a service by raising ill-founded fear for their future health.

Results

We identified 12 ART providers who maintain websites. These providers offered modern ART services in various cities across the country with information primarily in English. Some providers also published brochures in Urdu and English on their social media accounts. According to our exploratory key, the websites showed the following features:

  1. 1) Location: Most IVF centers are located in the capital and in the province of Punjab outside the capital, and the ART network in Pakistan is spread among nine cities throughout the country: Islamabad, Lahore, Faisalabad, Karachi, Multan, Sargodha, Hyderabad, Quetta, and Larkana. One IVF website had no physical location and promoted its services as follows: “People is our business and the World is our market and that includes your location.”Footnote 6

  2. 2) Landing page statements: On their landing pages, ART providers used highly emotional statements reflecting the pain of infertility, the joy of motherhood, and hopes for treatment and employed vague language when referring to costs or success rates. Examples include the following: “A woman has a natural urge to conceive and be a mother, without achieving this inherent desire she remains incomplete”Footnote 7; “Bringing Stars into families at affordable cost”Footnote 8; “The desire to have a baby is one of life’s most important and exciting decisions. We help make that dream a reality for thousands of couples every year.”Footnote 9

  3. 3) Ethical standards: Four out of 12 ART providers mentioned ethical standards on their websites. Two centers referred to Islamic ethical guidelines and another to guidelines by the American Society for Reproductive Medicine (ASRM), the American Society of Andrology, and the World Health Organization (WHO). Yet another center stated that it is following strict ethical considerations, without specifying any guidelines.

  4. 4) Quality certification: Despite the fact that quality assurance is the leading concern in the ART and RGT sector, only two centers mentioned certain quality standards, such as the International Organization for Standardization (ISO) 9001:2000 certification for providing quality and safety in healthcare services and certification of the laboratory facilities by the Clinical Laboratory Improvement Amendment (CLIA).

  5. 5) Highlighted services for prenatal sex selection: It is not surprising that most of the providers addressed the sociocultural preference for a son. Eight out of 12 websites offered preimplantation genetic diagnosis (PGD) and/or prenatal sex selection. Marketing statements include the following: “Infertile couples should pay attention! PGD Family Balance Technology”Footnote 10 and “100% success rate of sex selection with ICSI/PGD.”Footnote 11 We also found one IVF provider’s website appealing to an elevated status for women by describing them as the superior gender.Footnote 12

  6. 6) Foreign affiliations: Some providers used photographs or references to foreign doctors with the goal of increasing the value and trustworthiness of their centers in the eyes of prospective clients. Examples include Panayiotis Zavos, a Greek reproductive biologist associated with human cloning claims;Footnote 13 well-known politicians, such as the former Australian ambassador to Pakistan;Footnote 14 and Terrence Leonard, a certified embryologist in the United Kingdom.Footnote 15,Footnote 16

  7. 7) Call for financial donations: As the technology is expensive, and Pakistan has no public funding system for subsidizing ART, some providers pointed to the philanthropic potential of this medical advancement. Three websites called for financial donations to support patients who cannot afford treatment.

  8. 8) Social media accounts with online brochures and pictures: ART providers used social media to increase the knowledge of this technological advancement among Facebook and Twitter users. Five centers mentioned social media links on their websites. Some centers continuously updated their social media pages with ongoing activities, such as seminars, training sessions, information days, and special packages both in English and Urdu (e.g. one mentioned a discount package for Ramadan from June 15 to July 30, 2014).Footnote 17

  9. 9) Success rate of the center: Only three websites mentioned their success rate. However, these numbers were either outdated or described in imprecise language: “Birth of 1500 babies in short span,”Footnote 18 “take home baby rate of 16%,”Footnote 19 and “75% with 4 cycles of IVF and 3 pregnancies.”Footnote 20 Two centers declared that they have the “highest success rates” in the country, without elaborating further.Footnote 21,Footnote 22

Discussion

Infertility is a global phenomenon and a social burden, particularly in regions with poor access to ARTs and particularly for women.Footnote 23 Compared to Western countries, India, or the Middle East, Pakistan can be considered as one of the world’s underserved regions with regard to medically assisted reproduction facilities.Footnote 24 In its 2010 surveillance report, the International Federation of Fertility Societies (IFFS) mentioned 10 ART centers in PakistanFootnote 25 (the latest report from 2013 does not contain any data from PakistanFootnote 26). We found 12 ART providers that run websites. Analyzing their websites’ contents within the broader frame of globalized reproductive medical care and services, we identified several issues in the Pakistani ART/RGT landscape that are relevant for healthcare ethics, hold exploitative potential, and indicate a need for debates that stimulate public awareness and policy deliberation.

Lack of Regulation and Ethical Debate

In Pakistan no statutes or legal guidelines regulate the use of ART/RGT,Footnote 27 and assisted reproduction is not subsidized by public health funds. As stated in the 2010 surveillance report of the IFFS, these are conditions in which governance of ART/RGT is left to professional self-regulation and to “custom” and “beliefs associated with Islam,”Footnote 28 and it seems that in such settings “influences are at work other than the goal of good medical practice.”Footnote 29 In line with this observation by the IFFS and with a recent commentary on the perceived lack of self-monitoring by the medical profession in Pakistan,Footnote 30 we could not find any indication of regulation or oversight of the ART/RGT sector. Moreover, only four of the centers referred to ethical standards, and only one of them referred to those of professional associations related to reproductive medicine. Certainly, this does not mean that the ART centers currently operating do not have any good-practice standards or self-imposed guidelines. Some clinics, for example, investigate how they could improve their clinical services, as indicated by a recent study that aimed to better understand the “clinical and laboratory characteristics of the Pakistani females presenting themselves for in vitro fertilization in private setting.”Footnote 31 Nevertheless, there is a critical absence of transparency in this medical field in Pakistan. Other aspects exacerbate the problem: (1) the country lacks a sound and informed debate on the ethics of ART/RGT, (2) knowledge and perceptions regarding infertility in Pakistan’s population are limited and characterized by numerous misconceptions and myths,Footnote 32 and (3) infertility and its treatment by ART are still taboo topics for most of Pakistan’s society.Footnote 33,Footnote 34 Of concern for medical ethics, a situation of lacking oversight, limited debate, and prevalent ignorance increases the vulnerability of infertile women, men, and couples seeking ART/RGT treatment.

Sex Selection for Nonmedical Reasons

Most of the Pakistani fertility clinics’ websites we studied offer preconception (e.g., by sperm sorting) and preimplantation (by PGD) sex selection for nonmedical reasons, so-called family balancing. Sex selection for nonmedical reasons provided by ART is a highly controversial topicFootnote 35 that is hotly discussed in many countries, as is illustrated, for example, by Australian media debates.Footnote 36 On the other hand, it has also been pointed out that “in developing countries, particularly within an Islamic context, the availability of sex selection using PGD for non-medical reasons does have a positive social effect” by reducing suffering and economic hardship.Footnote 37 This seems to be also valid in the Pakistani context, as discrimination against women and male preference are common. Sons are regarded as symbols of prestige and supporting pillars for their parents in old age, whereas daughters are destined to leave the parents’ home after marriage. The traditional dowry system is another reason behind discrimination against daughtersFootnote 38,Footnote 39 For these reasons, having two to three sons and one daughter is still considered a family ideal. This situation has worsened due to the lack of a statuary social support system for the elderly.Footnote 40 According to the Global Gender Report of 2014, Pakistan ranked at position 141 out of 142 nations regarding gender equality, based on gender gaps in health, education, economy, and politics.Footnote 41 Moreover, most aborted fetuses and most abandoned children are female.Footnote 42 In line with this trend, the sex ratio at birth (SRB) in Pakistan deviates from normal—that is, the ratio is 109.88 males to 100 females, whereas the normal SRB is 104–106 males to 100 females.Footnote 43 In view of the widespread gender bias—which also becomes manifest in violence toward females through infanticide, child neglect, and selective abortionsFootnote 44—providing nonmedically indicated sex selection by means of ART calls for accompanying informed public debate and measures to overcome gender discrimination.

Insensitive Advertisement

Major ethical concerns regarding advertisement in the field of ART include truthfulness of information and sensitive use of images.Footnote 45 Nevertheless, we found that success stories are usually highlighted without paying heed to possible treatment failures, and success rates are either lacking altogether or presented confusingly. The emphasis on the desire to conceive and on the incompleteness of childless women on some of the websites resonates with the patriarchal orientation of Pakistan’s society. Thus, the standard of some of the websites’ advertisements for their services does not conform to the PMDC Code of Ethics,Footnote 46 which is restrictive toward commercialization and also prohibits the use of controversial and discriminatory statements.

Intercountry ART/RGT

Reproductive care is increasingly provided across borders, a global phenomenon termed cross-border reproductive care (CBRC), intercountry medically assisted reproduction (IMAR), or fertility tourism.Footnote 47 It is powered by a patchwork of global ART/RGT regulations and by socioeconomic asymmetries.Footnote 48,Footnote 49,Footnote 50,Footnote 51 Muslim countries, particularly in the Middle East, are also well-established CBRC destinations,Footnote 52 often for expatriates living abroad.Footnote 53 Although CBRC can improve the access and affordability of ART and thus be an important gender intervention in some contexts,Footnote 54 it has also developed into a thriving global market. Some of its expressions, called “fertility capitalism” by one author,Footnote 55 include exploitation of third parties; human rights violations; trafficking of gametes, embryos, women, and children; and medical malpractice. Surrogacy in India and Thailand is a well-documented example of this kind of ART business.Footnote 56,Footnote 57 Due to scarce data on Pakistan’s ART/RGT sector, its position in this international context is difficult to estimate. However, from our analysis and in context with some of the aforementioned threads, we assume that Pakistan plays a role in CBRC, and this calls for oversight and documentation in order to avoid exploitative practices. Our assumption is based on the following observations: (1) Several ART center websites clearly target international clients.Footnote 58 (2) In line with this, we found advertisements for IVF, ICSI (Intracytoplasmic Sperm Injection), and PGD packages that include accommodation, air tickets, procedure charges, and transportation for patients from the United Kingdom and the United Arab Emirates. The price ranges from 700,000 to 1,500,000 Pakistani rupees (about USD 6,750–14,430).Footnote 59 (3) Most centers provide PGD for “family balancing,” a procedure that has become a “market advantage”—as was shown for Thailand, a destination for AustraliansFootnote 60 and other foreignersFootnote 61 seeking this service.

Conclusion

Doubtless, ART and RGT have helped millions of couples around the globe to fulfill their wishes of parenthood, and Pakistani ART centers certainly provide admirable services to the community. However, due to the rapid advancement of the technology and its increasing commercialization on a global scale, its exploitative potential has to be considered. Our study indicates an imminent need to improve the quality of online information provided by ART centers in Pakistan. It is important to devise specific advertisement guidelines to help this sector conform to professional ethics standards. The societal vulnerability of the Pakistani population, particularly of females, calls for educating and raising awareness about this technology and for introducing uniform quality standards and regulation. For a society in which infertility is a stigmaFootnote 62 and giving birth to a son is a matter of prestige, promoting the use of ART and RGT for prenatal sex selection and employing irresponsible advertising slogans are of particular concern.

References

Notes

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