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AMA J Ethics. 2018 Mar 1;20(1):228-237. doi: 10.1001/journalofethics.2018.20.3.ecas1-1803.

Is Lower Quality Clinical Care Ethically Justifiable for Patients Residing in Areas with Infrastructure Deficits?

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The William K. Lanman, Jr. Professor of Anthropology and International Affairs at Yale University in New Haven, Connecticut.
A professor of obstetrics, gynecology, and reproductive sciences at Yale University in New Haven, Connecticut, where he also is director of the Yale Fertility Center and Fertility Preservation Program and serves as a bioethicist on the faculty at the Yale Center for Bioethics.


Reproductive health services, including infertility care, are important in countries with infrastructure deficits, such as Lebanon, which now hosts more than one million Syrian refugees. Islamic prohibitions on child adoption and third-party reproductive assistance (donor eggs, sperm, embryos, and surrogacy) mean that most Muslim couples must turn to in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) to overcome their childlessness. Attempts to bring low-cost IVF-ICSI to underserved populations might help infertile couples where no other services are available. However, a low-cost IVF-ICSI protocol for male infertility remains technically challenging and thus may result in two standards of clinical care. Nonetheless, low-cost IVF-ICSI represents a form of reproductive justice in settings with infrastructure deficits and is clearly better than no treatment at all.

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