Orange County Voices : COMMENTARY ON ETHICS : Allegations Regarding Fertility Clinic Shock Even the Hardened : Rather than pointing fingers, UCI officials, physicians and their lawyers should devote their energies to developing standards to prevent unethical behavior.

We have become so used to charges of ethical improprieties that they hardly make a dent anymore: Watergate, Whitewater, Orange County bankruptcy, celebrity indiscretions, congressional investigations.

But even those who have become jaded by these sorts of things are disturbed by reports about activities at the UCI Center for Reproductive Health. Physicians there have been accused not only of withholding reports of income and falsifying records, but also of intimidating staff, abandoning patients and--perhaps most shocking--transferring eggs and/or embryos without permission.

Officials at UCI have been accused of conducting a cover-up. If the allegations turn out to be true, physicians and officials have failed in their basic ethical duties, including respect for human dignity, truthfulness, and non-malfeasance (“do no harm,” the first principle of the Hippocratic Oath.)

Our shock at these allegations is great because we expect higher standards from physicians and medical institutions than from politicians and bureaucrats.

In the medical world--and especially in the mysterious world of infertility treatment--much more is at stake than money. People place their bodies, their health and, in this case, their hoped-for children’s very existence in a trusting relationship with physicians and medical institutions. The clear possibility that this trust has been abused requires us to ask not only about the ethical responsibilities of the individual doctors, but also about those of the medical institution and of society itself.

The logo for the Center for Healthcare Ethics at St. Joseph Health System has three concentric circles. The inner circle represents individual ethics; the middle ring, institutional ethics; and the outer ring, societal ethics. At each of these levels, the primary ethical concern is with human dignity, but respect for human dignity is achieved differently in each level.

In the case of reproductive technology, the individual level involves couples desiring a child and the expert health professionals who assist them. Women and men who seek the help of fertility specialists pay a lot, as much as $10,000 for one course of IVF (in-vitro fertilization) treatment, whose success rate may be less than 25%. People are willing to pay that much money for such poor odds because they desperately want a child. Desperation makes them very vulnerable, but they trust that they will not be mistreated when they put themselves in the hands of the physician, because physicians are professionals.

The term “professional” is applied to all those who, like physicians, have a body of specialized knowledge that is to be used in the service of others. Professionals are expected to conduct themselves in accordance with their profession’s code of ethics. For example, the current Code of Ethics of the American Medical Assn. says: “A physician shall be dedicated to providing competent medical service with compassion and respect for human dignity. . . . A physician shall deal honestly with patients and colleagues. . . .” Physicians are expected to put their patients’ interests before their own.

Most individual physicians do act ethically, but not always. So more than a professional code of ethics is required. This is when institutional ethics--the second level--becomes important.

Hospitals, too, have codes of ethics. One of these is the Patient Bill of Rights, assuring patients that they will receive quality care, information, privacy, confidentiality. In other words, respect for their dignity as persons. Institutions need periodically to do an ethical audit, to see if their actions match their statements.

That means looking at institutional policies, standards, “politics,” and cultural climate. For example, did the UCI Center for Reproductive Health have written procedures requiring and monitoring informed consent by egg donors? Did its policies require careful record-keeping as to the number of eggs retrieved and their disposition? Were physicians allowed to behave in ways that would not be tolerated in other staff? Was there a political climate that ignored staff who suspected unethical behavioral?

The largest circle of ethics, the societal level, expresses the societal values behind our public policy, laws, and regulations. Reproductive technologies are complicated and specialized, and they have not engaged the interest of the public in the same way as have, for example, questions about life-prolonging technology. However, some central human concerns are involved: parenthood, the rights of children to know their genetic lineage, the rights of egg and sperm donors to know generally what is being done with their gametes, the status of the embryo, and the allocation of health care resources.

Unfortunately, many of these and other issues are unresolved. The American Fertility Society’s 1994 ethics committee report lamented the lack of a public body to make recommendations on critical ethical issues involving infertility treatment. The committee points to major regulatory vacuums including the lack of uniform procedures by which reproductive centers accurately record and disclose pregnancy rates; the absence of mechanisms to certify professional competence, and no specific way to address the unique issues raised by pre-embryo freezing.

The scandal at UCI may finally provide the needed impetus to develop sound public policy in artificial reproductive technology. At least two governmental commissions have been established, one at the state level and one at the federal. These are welcome initiatives, but we cannot rely solely on improved government regulation to calm the troubled waters of this issue.

Indeed, no single level of ethics--individual, institutional, or societal--can be relied on to manage ethical issues. We need to work at it all, and we all need to keep working at it. We need to ask questions about the individuals, but also about the institutions that oversee the individuals, and about the society that oversees it all.

In the meantime, wouldn’t it be refreshing if officials at UCI, physicians at the fertility clinic, and their respective lawyers stopped pointing fingers at each other and acknowledged the emotional suffering that these alleged actions have produced?

Wouldn’t it be nice if they spent their energy finding systematic ways to assure quality of care and to prevent unethical behavior, rather than spending their energy on damage control?

Finally, wouldn’t it be helpful if we all remembered that honesty, in the short and the long run, is always the best policy?