Why is the Scottish Govt targeting women for egg donation?

[Nearly Sane]

Because there's been a facile acceptance of the idea of a right to a child rather than the needs of children.


https://unherd.com/thepost/why-is-the-scottish-government-targeting-women-for-egg-donation/

[Outrider]

"Some may be worried that public money has been used to push a practice many people consider unethical;"

Someone, somewhere has an 'ethical' objection to pretty much everything. Organ donation, blood transfusions, equal rights for women/gay people/people of colour...

At a time when we have an increasing demographic slant that needs solutions - more children isn't the only solution - and when we're increasingly clear that people outside of the 'traditional nuclear family' are perfectly capable of raising happy, well-rounded, capable children, I fail to see why there is a fuss about this.

O.

[Nearly Sane]

"Some may be worried that public money has been used to push a practice many people consider unethical;"

Someone, somewhere has an 'ethical' objection to pretty much everything. Organ donation, blood transfusions, equal rights for women/gay people/people of colour...

At a time when we have an increasing demographic slant that needs solutions - more children isn't the only solution - and when we're increasingly clear that people outside of the 'traditional nuclear family' are perfectly capable of raising happy, well-rounded, capable children, I fail to see why there is a fuss about this.

O.

So you are happy that a risky prodlcedure should be touted because of a 'right for people to have children', and tgat considerable amounts of tax money be spent supporting this 'right to have children'?

[Outrider]

So you are happy that a risky prodlcedure should be touted because of a 'right for people to have children', and tgat considerable amounts of tax money be spent supporting this 'right to have children'?

Short answer - yes.

All medical procedures have some risk - you say this is a 'risky' procedure, but two cited deaths over a decade ago (and this sort of fertility treatment is, in the grander scheme, one of the newer fields of medicine) out of how many? Is it riskier than, say, kidney donation (2.7 deaths per 10,000)?

As to the right to have children, why is that any less of a concern than other rights? We don't set standards for otherwise obviously unsuitable people to have children, despite the best interests of those children, but we should advocate for medical issues being allowed to deny people the full range of their life? Sorry, your medical condition that has an manifest restriction on your life (and your partner's life) isn't important enough to fund, and we have boob-jobs in the queue? There are always balances of individual and collective good in state-funded medicine, and whilst I can see some of the objections to this I don't think they outweigh the benefits, and I can see areas of state-funded medicine which are far, far less beneficial to the common and individual good than this to complain about.

O.

[SteveH]

Unnecessary, I'd've thought: there are always plenty of babies and children available for adoption.

[Nearly Sane]

Short answer - yes.

All medical procedures have some risk - you say this is a 'risky' procedure, but two cited deaths over a decade ago (and this sort of fertility treatment is, in the grander scheme, one of the newer fields of medicine) out of how many? Is it riskier than, say, kidney donation (2.7 deaths per 10,000)?

As to the right to have children, why is that any less of a concern than other rights? We don't set standards for otherwise obviously unsuitable people to have children, despite the best interests of those children, but we should advocate for medical issues being allowed to deny people the full range of their life? Sorry, your medical condition that has an manifest restriction on your life (and your partner's life) isn't important enough to fund, and we have boob-jobs in the queue? There are always balances of individual and collective good in state-funded medicine, and whilst I can see some of the objections to this I don't think they outweigh the benefits, and I can see areas of state-funded medicine which are far, far less beneficial to the common and individual good than this to complain about.

O.

Thank you for all that straw, Vlad hasn't been as regular with his deliveries. The 'argument' that there are other questionable  expenditures on the NHS, or question
able 'rights' are asserted, therefore this is fine is not a good one.

ETA - also that the state does not police people having children for suitability is not an argument for either a 'right to have children' or for spending tax money on enabling people to have children by 'artificial' means.

[jeremyp]

we should advocate for medical issues being allowed to deny people the full range of their life? Sorry, your medical condition that has an manifest restriction on your life (and your partner's life) isn't important enough to fund, and we have boob-jobs in the queue?

We do that already. NHS funding has never been completely adequate to cover every medical procedure that everybody wants doing. There are committees right now deciding which treatments are to be made available on the NHS. There are also long waiting lists for a number of simple treatments that improve people's quality of life. How do you measure people getting timely hip operations so they can walk again or timely cataract operations so they can see again against fertility treatments or boob jobs? How do you measure providing an expensive drug that might save your life against people wanting to have children or boob jobs?

I would suggest that fertility treatments should be very low priority on the NHS.

[ProfessorDavey]

We do that already. NHS funding has never been completely adequate to cover every medical procedure that everybody wants doing. There are committees right now deciding which treatments are to be made available on the NHS. There are also long waiting lists for a number of simple treatments that improve people's quality of life. How do you measure people getting timely hip operations so they can walk again or timely cataract operations so they can see again against fertility treatments or boob jobs? How do you measure providing an expensive drug that might save your life against people wanting to have children or boob jobs?

I would suggest that fertility treatments should be very low priority on the NHS.

While I fully understand the issues of resource allocation in the NHS, I'm not sure that is really relevant as the NHS already covers the cost of some types of fertility treatment (with certain rule on who and how much will be NHS funded). So if your fertility issues can be resolved by IVF without the need for a donor egg then NHS will cover. It seems strange to me, on that basis, that if your fertility issues cannot be treated by IVF without donation, but require donation of egg or sperm that you wouldn't also be covered to some extent by the NHS.

Either rule that fertility treatment isn't something that is allowable with NHS funds or if it is in principle use the standard NICE approach to approval which is based on clinical effectiveness and cost effectiveness. And if you are going to allow fertility treatment involving donated gametes, it makes absolute sense to try to ensure that there is a sufficient supply of those gametes to meet need.

[ProfessorDavey]

So you are happy that a risky prodlcedure should be touted because of a 'right for people to have children', and tgat considerable amounts of tax money be spent supporting this 'right to have children'?

Provided that those engaging with that risky procedure do so on the basis of consent, which would require them to be made aware of the risks involved, then I don't really see the issue.

[Outrider]

Unnecessary, I'd've thought: there are always plenty of babies and children available for adoption.

And whilst I'm always an advocate for adoption, there are some circumstances where it doesn't fit - having had two disabled children before, having more social services involvement in our lives is not the parenting experience we were looking for.

Thank you for all that straw, Vlad hasn't been as regular with his deliveries. The 'argument' that there are other questionable  expenditures on the NHS, or question able 'rights' are asserted, therefore this is fine is not a good one.

In this instance, yes it is. The argument is should we be putting public money up for this particular procedure, and implicit in that question is the balance of the good it does for the individual and society against the benefit of other procedures.

ETA - also that the state does not police people having children for suitability is not an argument for either a 'right to have children' or for spending tax money on enabling people to have children by 'artificial' means.

So the state should decide that some people can't have their own children, even though they might be perfectly suitable parents, but should decide that unsuitable people shouldn't be obstructed? I'm not in favour of intervention, in general, but if the state chooses not to provide certain services that's what they're doing.

We do that already. NHS funding has never been completely adequate to cover every medical procedure that everybody wants doing. There are committees right now deciding which treatments are to be made available on the NHS. There are also long waiting lists for a number of simple treatments that improve people's quality of life. How do you measure people getting timely hip operations so they can walk again or timely cataract operations so they can see again against fertility treatments or boob jobs? How do you measure providing an expensive drug that might save your life against people wanting to have children or boob jobs?

That was pretty much my point.

I would suggest that fertility treatments should be very low priority on the NHS.

You could suggest that, I certainly wouldn't put it at a high priority, but there are a number of currently provided treatments for other conditions and situations that I'd say should fall below it. Not to forget that, currently, these fertility treatments are available from at least some (maybe all?) NHS Trusts.

O.

[Nearly Sane]

Provided that those engaging with that risky procedure do so on the basis of consent, which would require them to be made aware of the risks involved, then I don't really see the issue.

I presume you mean 'made aware of and show that they understand'?

Even given that presumption, that still doesn't mean that the Scottish govt should be promoting it.

[Nearly Sane]

In this instance, yes it is. The argument is should we be putting public money up for this particular procedure, and implicit in that question is the balance of the good it does for the individual and society against the benefit of other procedures.

I'm missing how that's relevant to you using a strawman to suggest that in my questioning the spending on one thing on the NHS that I'm somehow accepting all the other decisions?

So the state should decide that some people can't have their own children, even though they might be perfectly suitable parents, but should decide that unsuitable people shouldn't be obstructed? I'm not in favour of intervention, in general, but if the state chooses not to provide certain services that's what they're doing.

Not providing fertility treatments is no 'the state deciding that some people can't have their own children'. You really did get a good deal on the straw.

[ProfessorDavey]

I presume you mean 'made aware of and show that they understand'?

Even given that presumption, that still doesn't mean that the Scottish govt should be promoting it.

Nope - the legal threshold for consent is the ability to understand and the provision of adequate and sufficient information. Consent does not require actual understanding, still less that an individual is required to show that they understand.

[Nearly Sane]

Nope - the legal threshold for consent is the ability to understand and the provision of adequate and sufficient information. Consent does not require actual understanding, still less that an individual is required to show that they understand.

Amazingly, I don't think that either laws are correct, or that when someone expresses a personal point on a matter of ethics on the board that I have to read into that that they just agree with the law as it stands.

I think that it's important in any situation like this that the person can illustrate that they understand the risk.

[Nearly Sane]

Nope - the legal threshold for consent is the ability to understand and the provision of adequate and sufficient information. Consent does not require actual understanding, still less that an individual is required to show that they understand.

Just to quote from the NHS conditions on consent

'capacity – the person must be capable of giving consent, which means they understand the information given to them and can use it to make an informed decision'

https://www.nhs.uk/conditions/consent-to-treatment/

[Outrider]

I'm missing how that's relevant to you using a strawman to suggest that in my questioning the spending on one thing on the NHS that I'm somehow accepting all the other decisions?

Because, as we've already established, NHS treatments don't exist in a vacuum, they're all competing for a slice of the same funding. I'm not suggesting that you're necessarily accepting any of the individual decisions, just pointing out that there it's not a simple 'yes/no', but rather a complex balance of 'either/or's.

Not providing fertility treatments is no 'the state deciding that some people can't have their own children'.

Functionally, yes it is. If you have poor income but fertility issues, if it's not available on the state the it's not available for you.

You really did get a good deal on the straw.

Keep throwing the straw, you might find an actual point under it.

O.

[Nearly Sane]

Because, as we've already established, NHS treatments don't exist in a vacuum, they're all competing for a slice of the same funding. I'm not suggesting that you're necessarily accepting any of the individual decisions, just pointing out that there it's not a simple 'yes/no', but rather a complex balance of 'either/or's.

Functionally, yes it is. If you have poor income but fertility issues, if it's not available on the state the it's not available for you.

Keep throwing the straw, you might find an actual point under it.

O.

Then if I'm not suggesting it, it's irrelevant to my point - which up till now you seemed sufficiently happy with to argue against - so I'll take your comment on not having one with a pinch of salt.


In not supplying fertility treatment the govt, it's not saying peoole are unsuitable, and given you've said you woukdn't have it as the highest priority, and therefore wouldn't be supplying it to everyone who asked, by your logic you are happy to deny it to people you regard as unsuitable.

[Outrider]

Then if I'm not suggesting it, it's irrelevant to my point - which up till now you seemed sufficiently happy with to argue against - so I'll take your comment on not having one with a pinch of salt.

There are any number of pertinent points that you've not raised that are worth introducing - that you've not mentioned it before doesn't make it taboo, you aren't the arbiter of relevance.

In not supplying fertility treatment the govt, it's not saying peoole are unsuitable

I didn't say that they were, I said that they weren't preventing unsuitable people having children, but if they opted not to fund fertility treatment that they would be denying children to otherwise suitable people.

... and given you've said you woukdn't have it as the highest priority, and therefore wouldn't be supplying it to everyone who asked

Or I'd be supplying it to everyone who asked at the expense of some other treatment that I think is less 'worthy'.

by your logic you are happy to deny it to people you regard as unsuitable.

Apparently not.

O.

[ProfessorDavey]

Amazingly, I don't think that either laws are correct, or that when someone expresses a personal point on a matter of ethics on the board that I have to read into that that they just agree with the law as it stands.

I think that it's important in any situation like this that the person can illustrate that they understand the risk.

But that isn't what the law says - the law does not require actual understanding, but does require the ability to understand. And the assessment of capacity to consent is based on the ability to understand.

[ProfessorDavey]

Just to quote from the NHS conditions on consent

'capacity – the person must be capable of giving consent, which means they understand the information given to them and can use it to make an informed decision'

https://www.nhs.uk/conditions/consent-to-treatment/

Oh dear - the curse of the armchair expert who has access to google.

This is a simplistic summary, rather than a detailed critique of the nature of capacity to consent and its assessment. But even so if you click the 'read more' link to here:

https://www.nhs.uk/conditions/consent-to-treatment/capacity/

You will see that in more detail we begin to see 'ability' appearing e.g.:

"Capacity means the ability to use and understand information to make a decision, and communicate any decision made."

And when you delve into stuff aimed at professionals rather than the lay person it is clear that the legal test for capacity involves the ability to understand, not necessarily actual understanding - e.g.:

https://www.proceduresonline.com/resources/mentalcapacity/p_ment_cap_assess.html

"The functional test of capacity

The functional test consists of 4 elements, each of which you must test the person's ability in. They are:

The ability to understand information about the decision (the 'relevant' information);
The ability to retain the information long enough to make the decision;
The ability to use, or 'weigh up' the information as part of the decision making process; and
The ability to communicate their decision through any means."

If you were one of my masters students and you wrote in an exam that capacity to consent required actual understanding - zero marks for you.

[jeremyp]

Oh dear - the curse of the armchair expert who has access to google.

This is a simplistic summary, rather than a detailed critique of the nature of capacity to consent and its assessment. But even so if you click the 'read more' link to here:

https://www.nhs.uk/conditions/consent-to-treatment/capacity/

You will see that in more detail we begin to see 'ability' appearing e.g.:

"Capacity means the ability to use and understand information to make a decision, and communicate any decision made."

And when you delve into stuff aimed at professionals rather than the lay person it is clear that the legal test for capacity involves the ability to understand, not necessarily actual understanding - e.g.:

https://www.proceduresonline.com/resources/mentalcapacity/p_ment_cap_assess.html

"The functional test of capacity

The functional test consists of 4 elements, each of which you must test the person's ability in. They are:

The ability to understand information about the decision (the 'relevant' information);
The ability to retain the information long enough to make the decision;
The ability to use, or 'weigh up' the information as part of the decision making process; and
The ability to communicate their decision through any means."

If you were one of my masters students and you wrote in an exam that capacity to consent required actual understanding - zero marks for you.

So it would be ethical to continue with a treatment on somebody who has the capacity to understand the information about it but where it is evident that they actually do not understand the information for whatever reason e.g. they misheard or misunderstood some point. That appears to be what you are claiming.

[ProfessorDavey]

So it would be ethical to continue with a treatment on somebody who has the capacity to understand the information about it but where it is evident that they actually do not understand the information for whatever reason e.g. they misheard or misunderstood some point. That appears to be what you are claiming.

Firstly we are discussing the legality not the ethical position - while they are, of course, linked they are not the same thing.

But also consent is a process, it is not a one off event. So were a professional to become aware that a person might have misheard or misinterpreted a point then they would be well advised to ensure that the consent remained valid.

But that isn't what we are talking about - we are discussing whether actual understanding is a requirement for capacity to consent - it isn't. And it isn't for both obvious, and less obvious reasons. The obvious is that the medical profession would have to test actual understanding, which would potentially be impossible or unethical, in order to determine whether treatment was valid under consent. But there is another point - consent is about arriving at a decision, nor about whether that decision is deemed by others to be rational or sensible. So the reasonableness of the decision in the eyes of others has no bearing on whether that decision is consensual.

So a person may refuse to engage with the information and make a decision that others may feel is completely unreasonable or irrational - that wouldn't mean that they did not have capacity to consent nor that their consent wasn't valid.

[ProfessorDavey]

So it would be ethical to continue with a treatment on somebody who has the capacity to understand the information about it but where it is evident that they actually do not understand the information for whatever reason e.g. they misheard or misunderstood some point. That appears to be what you are claiming.

There is also an element for capacity to consent about believing the information. So for someone to have capacity to consent they must believe information that is demonstrably true. So refusing to accept that you have a particular condition despite the evidence being clear might contribute to someone being considered to lack capacity to consent.

Another key element is the ability to retain the information.

But if you have the ability to understand the information, can retain the information, believe the information and can arrive at a choice then you will be considered to have capacity to consent. That remains the case even if you choose to ignore that information and/or make a decision that appears to most to be totally irrational.

[jeremyp]

Firstly we are discussing the legality not the ethical position

Are we? I'll have to review the thread, but I wasn't aware of anybody questioning the legality of what the Scottish government is doing, only whether it is right. Let me just check....

... Yep. I don't see anybody questioning the law. You first brought up the law in response to NS saying

I presume you mean 'made aware of and show that they understand'?

But also consent is a process, it is not a one off event. So were a professional to become aware that a person might have misheard or misinterpreted a point then they would be well advised to ensure that the consent remained valid.

Is this the law still, or just your opinion? If it's the law, then I think it justifies NS's comment (quoted above) unless you are going to nit pick the distinction between "not showing they don't understand" and "showing they do understand".

But that isn't what we are talking about - we are discussing whether actual understanding is a requirement for capacity to consent - it isn't.

Yes, but you also said this

But if you have the ability to understand the information, can retain the information, believe the information and can arrive at a choice then you will be considered to have capacity to consent.

It would be hard to argue that a person has not understood the information if all of those conditions must apply.

And it isn't for both obvious, and less obvious reasons. The obvious is that the medical profession would have to test actual understanding, which would potentially be impossible or unethical, in order to determine whether treatment was valid under consent. But there is another point - consent is about arriving at a decision, nor about whether that decision is deemed by others to be rational or sensible. So the reasonableness of the decision in the eyes of others has no bearing on whether that decision is consensual.

So a person may refuse to engage with the information and make a decision that others may feel is completely unreasonable or irrational - that wouldn't mean that they did not have capacity to consent nor that their consent wasn't valid.

Refusing to engage is not the same as failing to understand.

You are arguing fine points of legality in a discussion about right and wrong. That's just not a convincing argument.

And as for "testing understanding" I am pretty sure a good doctor would do that, informally. I have been fortunate not to be in the situation, but I would hope that, if I was about to give consent for a risky procedure the doctor would explain the risks and ask if I understood. If my responses indicate in any way that I didn't understand, I would hope they would try to rectify the situation.

Anyway, as I said. This isn't about what is legal. You are the only one bringing up the law. This is about what is right or wrong.

[ProfessorDavey]

Are we? I'll have to review the thread, but I wasn't aware of anybody questioning the legality of what the Scottish government is doing, only whether it is right. Let me just check....

... Yep. I don't see anybody questioning the law. You first brought up the law in response to NS saying:

"I presume you mean 'made aware of and show that they understand'?"

I'm not questioning the top level issue of whether what the Scottish Government is acting lawfully.

My point was a much narrower one - specifically whether it is legal (or ethical) for a medical procedure to proceed on the basis of consent if the medical practitioner has not been able to demonstrate that the person receiving the procedure has actually understood consequences etc. And the answer is that it would be - actually both legally (which is an objective test) and I would suggest that although ethical opinion is more subjective the position on consent is pretty settled. So in both cases the test is that the individual has the ability to understand, whether or not the individual actually understands is not required for capacity to consent.