Reproduction in life and death: should cancer patients with a poor prognosis be offered fertility preservation interventions?

In the context of a cancer diagnosis, fertility preservation interventions are used to mitigate the potential impact of gonadotoxic cancer treatment upon fertility. They provide patients with cancer the option to freeze their reproductive material to have their own biological child following treatment. The evidence suggests some clinicians are less likely to have fertility preservation discussions with patients who have an aggressive or metastatic cancer which has a poor prognosis. Although this is contrary to current policy recommendations, there is a lack of guidance relating to offering fertility preservation in the context of a poor prognosis to support clinicians. Controversy surrounds posthumous reproduction, and whether the wishes of the cancer patient, when living and deceased should take precedence over others' well-being. We consider the question of whether cancer patients with a poor prognosis should be offered fertility preservation from an ethics perspective. We structure the paper around key arguments to which multiple ethical principles might pertain, first establishing a central argument in favour of offering fertility preservation based on respect for autonomy, before exploring counterarguments. We conclude by proposing that a defeasible assumption should be adopted in favour of offering fertility preservation to all cancer patients who might benefit from it. It is important to recognise that patients could benefit from fertility preservation in many ways, and these are not limited to having a parenting experience. The burden of proof rests on the clinician in collaboration with their multidisciplinary team, to show that there are good grounds for withholding the offer.Lay summary When a person is diagnosed with cancer, they may wish to consider undergoing fertility preservation procedures. These procedures give patients a chance to have their own biological child after completing cancer treatment. However, research suggests that cancer patients who have a poor prognosis are less likely to be offered fertility preservation treatment. In this paper, we consider the ethical implications of offering (or not) fertility preservation to this patient group, including using their sperm or eggs to reproduce after their death. We conclude that fertility preservation treatments should be offered to all cancer patients who might benefit from it, and we outline the many ways that benefit from this treatment can be gained. The decision to withhold the offer of fertility preservation treatment should be made between the patient's clinician and their wider care team. They must be able to provide good reasons to explain why it was withheld.