How has this become an issue? Reproductive technologies permit procreation in manners that will not be possible by sexual intercourse and in manners hitherto unimaginable. a child can come from –parents who have never met (donor gametes), –a parent who died years in the past (posthumous use of gametes or embryos), –a pregnancy of his grandmother (postmenopausal pregnancy), or –indeed a woman unrelated to him/her genetically (surrogacy).
How has this become an issue? A most peculiar branch of medicine the treatment of infertility calls for the creation of another human being! Reproductive technologies result in the creation and existence of human embryos in vitro The creation of supernumerary embryos the need to deal with “life-and-death” decisions about inchoate human beings
Ethics Issues RT itself Access to RT services –Financial –Marital status: single or homosexual couples –Child-rearing ability: desirable parents –Age Multiple pregnancy & Selective Fetal Reduction
Objections to RT interference with Nature or playing God disregards the sanctity of every human life violates the sanctity of marriage & the family involvement of a third party effects on human rights, social structure & health policy
RT Arrangements married couple Surrogate mother Agent Service provider
Principles of Biomedical Ethics Beneficence Non-maleficence Autonomy of persons Justice Beauchamp & Childress
How do these principles apply to RT treatments? RT treatments are consistent with the ethical principles of beneficence and autonomy Do they do any harm? The question of justice
Beneficence Relief of the suffering and sorrow of those afflicted with infertility, Offering them a ray of hope and the possibility to enjoy the blessings of rearing (biologically related) children.
Infertility Hurts! Infertility Hurts! a crisis of the deepest kind threatens one’s sense of self, one’s dream for the future and one’s relationship with others feelings of anger, guilt, denial, blame, self- pity and jealousy predominate loss of control isolation from friends and relatives
Non-maleficence minimize risk and harm to all parties concerned, especially taking into account of the “welfare of the (unborn) child Congenital anomalies Physical & psychological development Multiple pregnancies
Justice and Equality equitable access to the use and benefits of reproductive technologies can one prohibit access by other persons? –Unmarried couples –Scarcity of resources –Absence of infertility (lesbians and single women) –Preservation of fertility
Child-rearing ability & provision of RT services Welfare of the child Procreative right of infertile persons Autonomy of service providers
Welfare of the child Parents who are psychologically unstable abuse drugs have a record of violence to family members
Procreative rights Fertile persons (reproduce coitally) no systematic screening of their ability or competency to rear children such actions not considered to be appropriate Why should infertile persons be denied services merely because they are infertile?
Autonomy of service providers Treatment of infertility calls for the creation of a child (human being) Physicians have a moral responsibility for the situation of the resulting child and may choose not to help bring about such an outcome On the other hand, physicians have a moral obligation to help persons in need
Respect for Autonomy I From a moral perspective, the acceptability of the “normal” desire to procreate is constrained by a number of factors : –transmission of a serious disease to the offspring, –unwillingness to provide decent prenatal care,
Respect for Autonomy II –inability to rear children, –procreation will engender massive identity problems or other serious impediments to normal psychological development for the offspring so created, and –strain on scarce resources of the community.
Iatrogenic Multiple Pregnancies Oocyte recoveries 27.3% twin deliveries & 3.4% delivery of triplets or more in 1998 worldwide Since 1970, triplet deliveries have increased 3 – 5-fold and twins, 30 – 50% Preterm, SGA and perinatal mortality Long-term consequences neuro- developmental disorders
Prospective parents’ autonomy consider higher-order pregnancy as a positive outcome underestimate the difficulty of raising multiples the emotional stress of the infertility and the strong desire for a child financial context maximize the “benefit”
Physician’s autonomy responsible for the implications of his actions for the mother and the unborn child(ren) Moral obligation to cancel the cycle or to restrict the number of embryos replaced
Justice in IMP Financial pressure less well off couples are forced to accept the risk of multiple pregnancy Possible solution: public subsidies for ART
Non-maleficence Not to cause unnecessary harm both to the mother and the future children Moral responsibility to reduce the number of multiple pregnancies above the increase in pregnancy (success) rate
Selective Fetal Reduction (SFR) The explicit intention is not to terminate the pregnancy but to improve the chance of survival of the remaining fetuses (cf abortion) Decision psychologically and morally demanding infertile couples value all embryos/fetuses
Other issues Embryo cryopreservation Family members as gamete donors and surrogates Fertility treatment when the prognosis is futile (0 or ≤ 1%) Preservation of fertility HIV