In a case study published in AMA Journal of Ethics, Marcia C. Inhorn, PhD, MPH, and Pasquale Patrizio, MD, MBE, discuss the ethical challenges and potential solutions to providing infertility health care to individuals residing in areas with infrastructure deficits.

The case study focused on the story of a reproductive endocrinologist who arrived in Lebanon, a region with significant infrastructure deficits and a high population of Syrian refugees, to discuss with fellow clinicians how best to offer infertility treatment (ie, in vitro fertilization plus intracytoplasmic sperm injection [IVF-ICSI]) to individuals residing in this region. The physician suggested providing a mobile laboratory to patients to perform IVF-ICSI; however, the success rate in this setting is typically low. Despite its low efficacy, the doctor argues “that it’s better than these patients having no access at all to IVF-ICSI.”

This case presents an ethical dilemma that is rather common in the health care of individuals residing in areas of infrastructure deficits. Although there exists an ability to provide health care to these individuals, the quality is often compromised because of the medium in which the health care is provided. The concept of offering low-quality care vs no care at all may still be ethically sound, according to the investigators, particularly if that care is low cost for providers as well as patients. If the care is low cost, then it can be repeated, resulting in higher chances of success rates.

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In Lebanon, many parents who are infertile may be eager to have children, given all that they have lost. This may strengthen the argument that providing low-quality healthcare in these regions is of utmost importance. Because infertility is not a life-threatening condition and does not hold the potential for harming the patient, low-quality care vs no care is also seen as ethically justifiable.

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According to the investigators, infertility treatment disparities in Lebanon will continue until more initiatives can be developed and implemented to provide low-cost infertility treatment and “until (a) the tragic Syrian civil war ends, (b) the refugee crisis abates, (c) American troops are withdrawn from the Middle East region, and (d) peace prevails across this troubled land.”


Inhorn MC, Patrizio P. Is lower quality clinical care ethically justifiable for patients residing in areas with infrastructure deficits? AMA J Ethics. 2018;20(3):228-237.