Pamela White provides a brief English-language summary of the recommendations of the recently released report of the Quebec Commission à la santé et au bien-être.
On June 6, 2014, the Quebec Commission à la santé et au bien-être released its review of Quebec’s assisted human reproduction program. Since 2009, Quebec has offered public funding of assisted reproductive services. At the heart of the Commission’s report are twelve recommendations, several of which target measures designed to address psychosocial and ethical issues. Others aim to reduce costs, implement health surveillance, and—similar to the process in place in Britain—implement parental suitability screening. At the same time, the Commission rebuffs the model of a centralised governance body as has been established in the UK and France, instead recommending an ostensibly more inclusive and flexible permanent multi-disciplinary committee and Ethics table. The report also addresses the matter of abandoned embryos and recommends consultation on surrogacy.
The first section of the report explains how the Commission undertook the program review. It notes that the population is divided between Quebecers proud of the province’s non-discriminatory delivery of assisted reproduction services and concerned about its continuation. A detailed legal, economic and social portrait of Quebec’s program together with an assessment of its health impacts and costs situates the existing program and sets the stage for the Commission’s recommendations. The first part of the report alone is worth the read. The Commission should be commended for its fulsome program and legal review, its focus on evidence based decision-making, and emphasis on maternal and child health surveillance.
The second section presents twelve general recommendations made to improve the provision of assisted reproduction services. The first three recommendations seek to reduce costs and increase regional access. In Recommendation 1, which imposes access restrictions for reasons such as maternal age, elective fertility preservation and voluntary sterilization, the Commission leans heavily on the UK experience. Recommendation 2 addresses regional access inequalities, while the third recommendation proposes the imposition of a means tested payments. While Quebecers will undoubtedly welcome improvements to regional availability, recommendations regarding access restrictions and payments may prove to be less well received. The governance of assisted reproduction in Quebec is the subject of the fourth, fifth, and sixth recommendations. Given the Commission’s focus on health surveillance, it is not surprising that the fourth recommendation promotes data system integration and health research coordination. The fifth recommendation advises against establishing a centralized agency as exists in the United Kingdom and France, as the Commission asserts that this model is overly bureaucratic and cumbersome. The recommended approach is a multi-disciplinary committee complemented by an Ethics table. The existing ethics review process is tweaked in Recommendation 6.
To improve service provision, the seventh recommendation seeks continuity of service delivery among centres (primary, secondary and tertiary; public and private). The eighth recommendation mandates the use of standardized patient information, consent forms and counselling in all centres and clinics.
The Commission’s remaining recommendations centre on psychosocial matters, ethical issues and social choices. The ninth recommendation adopts the approach used in the United Kingdom to assess parental suitability. Intended parents would be required to complete and sign a declaration documenting past psychosocial issues (addictions, child welfare matters, etc.). Much ink has been spilt in the UK over the intrusion of the “nanny state” in family reproduction, and the recommendation to intervene in who is a “suitable” parent may be among the more contentious.
Patient “shopping” for assisted reproduction services was viewed as imposing unnecessary burdens on and creating risks for clinics. The tenth recommendation proposes the development of a patient database accessible by all clinics to track in real-time patient contacts, clinical interactions and psychosocial assessments. While not explicitly noted, appropriate privacy and data protections will need to be part of any implementation strategy.
In its eleventh recommendation, the Commission calls for the funding of both open-identity and anonymous sperm. Currently Quebec covers the cost of anonymous sperm acquisition only. The need for better documentation of donor characteristics, existing legal constraints to mandating use of open-identity gametes, and the psychosocial benefits of having access to information about one’s biological origins are also explored. While no specific recommendations were made on these topics, the Report opens the door on change.
The twelfth recommendation calls for the examination of embryo storage consents and disposition processes. A moratorium on clinic disposition of embryos lacking explicit disposition consent agreements is recommended .The Commission also advises that a public discussion on surrogacy be undertaken.
Overall, the Commission’s report reflects its in-depth research, and concern with cost containment, equality of access, and welfare of the child. Yet, the recommendations range from the very specific to the more general with all topics appearing to have equal weight and importance. There is no information about what these recommendations might cost to implement. While the Report opens the door to future regulation and further discussion of assisted reproduction, much remains to be explained about how Quebec’s program will now proceed.
Pamela M. White is a Specialist Associate Lecturer, Kent Law School, University of Kent.