Ethics of Reproduction

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Chapter 10 Ethics of Reproduction

Pasquale Patrizio, Dorothy Greenfeld

INTRODUCTION

Reproductive medicine and the use of assisted reproductive technologies (ART) for the treatment of infertility have rapidly evolved. Because these techniques are directly involved in the handling of human gametes and embryos, they are open to a number of ethical analyses and moral concerns. In addition, with the practice of ART, the union in vitro of gametes has also created situations where the boundaries of science, religion, interest of the society, and family law are all intermingled with the rights of individuals to reproduce, thereby creating various dilemmas for both patients and professionals. The complexities of the different clinical scenarios call for the creation of policies—currently in the format of voluntary guidelines—so that ART clinics can utilize a rational approach when deciding in favor of or against participation in the use of technologies for a particular reproductive scenario. Before discussing some of the most common ethical dilemmas in ART, it is necessary to provide some background information and explain the most common medical ethical constructs used to formulate policies and guidelines.

GENERAL ETHICAL CONSTRUCTS

Any policy or guideline needs to have a certain degree of flexibility built in, because natural rights and human dignity, in the context of creating families, cannot always be clearly defined. We do not have unequivocal answers regarding when life begins, which leaves room for debate in the discussion of the ethics of researching on embryos to obtain stem cells. Furthermore, if we recognize the natural rights of individuals to reproduce, why should this right not be conceded to same-sex couples?

It is understandably difficult to balance an individual’s right to reproductive autonomy and privacy with the societal obligations to protect the potentiality of life. A recent ruling by a judge in Chicago that a couple can sue a fertility clinic for wrongful death of an embryo not cryopreserved further exacerbates this moral confusion.1

The most common ethical norms used to conduct ethical analyses are based on principle-based ethics, communitarian-based ethics, and case-based ethics.

Principle-based Ethics

The moral reasoning of principle-based ethics is based on four principles: autonomy, beneficence, nonmaleficence, and justice.

Autonomy

Autonomy, or respect for persons, acknowledges an individual’s right to hold views, make choices, and take actions based on personal values and beliefs. This principle is at the base of informed consent and respect for privacy. In the reproductive field, this principle is the basis for reproductive rights and reproductive choices. Some examples: Should in vitro fertilization (IVF) be allowed for a woman who knows the donor of the sperm but does not intend to have a relationship with him? Should an unmarried woman be allowed to use donated embryos or sperm from a sperm bank? Should a woman in a long-term lesbian relationship be allowed to use sperm from a known or unknown donor? Should a widower be permitted to use embryos frozen while his wife was alive and to use a member of his or her family as a gestational carrier? Is it permissible to allow gay men in stable relationships to create families using donor eggs and surrogacy?

As to each question posed, the formulation of guidelines must take into account the right of an individual to decide, with the understanding that procreative liberty has some limits when these rights conflict with the child’s interest.

Beneficence

The principle of beneficence represents the obligation to promote the patient’s well-being. Beneficence represents the balancing of risks and benefits of an intervention. It is the principle that dictates that subjects be protected from harm and that efforts be taken to secure their well-being. It may conflict with the principle of autonomy. Examples where this principle comes into play include a patient who demands a cesarean section and a patient who requests the transfer of five or more embryos.

Nonmaleficence

The principle of nonmaleficence is the obligation of “do no harm,” also known by its original Latin expression of “primum non nocere,” which must be balanced with the principle of autonomy. Both beneficence and nonmaleficence may overlap, as, for example, in the case of a patient who refuses to receive a lifesaving blood transfusion or a patient who, despite having a very little chance of success and despite previous IVF attempts, insists and demands additional IVF treatments.

Justice

The principle of justice concerns fairness and equity (i.e., the need to be fair in sharing the burden [costs] and the distribution of resources [benefits] to all members of the community). In particular, the concept of distributive justice is often applied to situations requiring a decision about the equitable allocation of resources. The current practice of IVF, however, is not just. State variations in insurance coverage for IVF and the frequent determination by insurance companies that infertility is “not a disease,” make infertile low-income people unable to have access to these services. Particularly with third-party reproduction (egg donation and surrogacy), it is clear that at present, only wealthy couples can afford these reproductive services.

In terms of research, the principle of justice stipulates that one class of persons, due to their inherent vulnerability, may not be overrepresented as research subjects so that others may benefit. Moreover, it means that these same classes of persons may not be unduly excluded from research participation and denied the benefits derived from it.

Communitarian-based Ethics

In communitarian-based ethics, the moral reasoning emphasizes the interest of the community over individual autonomy. Solutions to ethical questions are to be formulated keeping in mind values and goals that benefit the need of many instead of few. Classical examples are the decisions to report cases of sexually transmitted disease (including human immunodeficiency virus). In ART the interest of the community could be affected if pre-implantation genetic diagnosis (PGD) for gender selection would be widely applied and would consistently favor the selection of one gender.

Case-based Ethics

In case-based ethics, the moral reasoning is based on previous solutions set for specific cases. It is analogous to case law in jurisprudence and because it asserts priority of practice over theory, it may conflict with and reject the primacy of the principles.

Because there is not one fundamental approach on which to rely exclusively, the practical use of medical ethics is a mix of all of these approaches. In summary, the moral principles should be applied in the context of community interest, respecting gender equality and building (if available) on the foundation of prior good ethical reasoning.

There are several clinical situations that are common in reproduction and are associated with introspection and debate. Some of these case scenarios are reviewed in this chapter.

MOTHERHOOD IN ADVANCED AGE

Programs offering fertility services are increasingly faced with requests from women of advanced reproductive age who seek assistance to become pregnant. Oocyte donation has afforded older women the opportunity to give birth well beyond menopause, and many are taking advantage of this opportunity. Without clear guidelines programs have concerns about the ethical propriety of this extension of the normal reproductive age. As a result they struggle with the following questions: Given that menopause no longer constitutes a biological limit to reproduction, when is a woman too old to give birth? How should the risks of pregnancy in older women be weighed against the rights of women to control their own reproductive lives? How should a woman’s age and life expectancy factor into a clinic policy concerning these services? What do we know about the capacity for postmenopausal women to parent infants and toddlers? What do we know about the development of children resulting from such services and how they fare as the children of comparatively aged parents?

There is no question that the phenomenon of older women seeking to become pregnant through egg donation has increased greatly in the past decade. In the United States between 1991 and 2001, the birth rate for women between ages 40 and 44 increased by 70%, and in 2003 there were 263 births reported in women between ages 50 and 54.2 Although a small number of these births occurred spontaneously, most are attributable to egg donation.3

Why do women of advanced reproductive age want to have children? Their motivations vary widely. A part of the explanation involves the fact that women are marrying later in life, often working in pursuit of their careers and consequently postponing motherhood. Of these women, some have been involved in prolonged infertility treatment with no success and have been referred to egg donation. Others are divorced and remarried and want to have children with their new husbands. In some cases the death of a child prompts a woman to attempt to have another.4 One study found an increased incidence of cosmetic surrogacy among older candidates for oocyte donation and suggested that the desire for pregnancy in this population is motivated by the “desire for youth” and the younger appearance that pregnancy provides.5

How Old Is Too Old?

The question, according to Sauer, has not been answered because the long-term consequences of pregnancy in older women are unknown. He describes the irony that older women, whose ages ordinarily would mean that they would have the poorest prognoses for pregnancy, with donor eggs now have the highest success rates in ART.6 The question of how old is too old presents an ethical dilemma for ART programs because the medical risks are disputable and guidelines for appropriate age restrictions are inadequate. Thus, programs offering oocyte donation are left to their own devices for determining age limits.

Pregnancy complications in older women (women over age 40) are well known. They include pregnancy-induced hypertension, premature rupture of the membranes, vaginal bleeding, and gestational diabetes.3 Those arguing against ART for older women say that this treatment exposes older women to physical risks wholly different from those that younger women are exposed to—risks to the cardiovascular system, for example. Older women have a greater chance of postpartum hemorrhage and are at greater risk for perinatal mortality, cesarean section, and multiple gestations.

Those in favor of this treatment argue that studies on older mothers are misleading because they include spontaneous pregnancies, women who have not been prescreened before pregnancy, women who are socioeconomically disadvantaged, and women who were in poor health before pregnancy.6,7 They contend that women over age 40 entering oocyte donation programs are typically rigorously screened before acceptance into the program. One study reported on women in their sixth decade of life who had safely delivered babies and presented no problems.6

Discipline-wide guidelines are inconsistent or entirely lacking, so programs have no generally accepted standards to provide guidance in making decisions about these patients. For example, the American Society for Reproductive Medicine (ASRM), in its Practice Guidelines, recommends that all recipients of oocyte donation over age 45 undergo thorough medical evaluation, including cardiovascular testing and a high-risk obstetrical consultation before treatment. The guidelines do not include recommendations for age restrictions, however.8 A statement from the ASRM Ethics Committee asserted that oocyte donation to postmenopausal women “should be discouraged” and that patients and programs should determine on a case-by-case basis whether a woman’s health, medical and genetic risks, and provision for child rearing justify proceeding with treatment.9

What About the Children?

Concerns about the children of older mothers seem to fall into two categories: one is about the life expectancy of the mothers and the fear that children will be orphaned at an early age; the other is about the health of the older mothers and the fear that they will not have the energy and the stamina to care for young children. The Human Fertilization and Embryology Authority (HFEA) law enacted in 1990 in the United Kingdom determined that recipients of donor oocytes should not be over age 45, based on the view that it is in the best interest of the child to be parented into young adulthood. Another clinician in the United States used the same argument—that children need an adult to raise them until they can live independently—but recommended that the treatment should be limited to women under the age of 60.10 Those arguing in favor of oocyte donation for postmenopausal women say that society is accepting of older men marrying younger women and having children, so to deny treatment to older women would be agist and sexist. In making this argument they ignore the fact that many older men are biologically capable of fathering children if they choose to do so, so that treatment issues enter into the equation only if donor sperm are required. They also argue that grandparents often take on the parenting role and “bring economic stability, parental responsibility, and maturity to the family unit,” so there is no reason to assume that older women would lack the stamina to raise children.9

It is unclear whether legislators or physicians are better able to judge an older woman’s suitability to be a mother than the woman herself. If an age guideline is to be evidence based, rather than a personal judgment, we presently do not have adequate data to determine an appropriate age limitation. Perhaps the most useful guideline would be to conduct a careful psychological evaluation of older women requesting this treatment, assessing their physical and emotional health status, and inquiring whether they have considered issues and potential problems of raising children in late middle age.

TREATING SAME-SEX COUPLES

An increasingly common ethical concern in fertility treatment centers offering ART is whether or not to accept couples of the same sex as patients. Often the question applies only to gay male couples because many clinics may already routinely treat lesbian women. Yet in recent years gay men as well as lesbian women have become more open about their homosexuality, their relationships, and their determination to become parents.11,12 There has been dramatic recent growth in societal awareness about homosexuality and acceptance of same-sex civil unions. In addition, a growing body of research supports the notion that being reared in homosexual homes does not harm children and that such children are not more likely to become homosexuals themselves.12 These factors have led more ART programs to consider treating same-sex couples of both genders.

A recent survey of ART programs in the United States makes clear that there is no consistent policy regarding the issue of treating same-sex couples, although programs are more likely to reject gay males than they are lesbians.13 Neither is there consistency in ethical concerns about this treatment. Concerns range from questions about the health and well-being of children conceived in all homosexual relationships to specific concerns about the children of gay men. Some common questions about gay fathers include: Can men (and in particular, gay men) be sufficiently nurturing? Are gay men more likely to be pedophiles that abuse their children? Are the sons of gay men more likely to become gay? Others may question whether it is ethically acceptable for programs to accept lesbians for ART while refusing to treat gay males.

Why do lesbian and gay couples want to become parents? It seems that they are motivated by the same factors that motivate heterosexuals to become parents. In fact, a recent study looked at desire and motivation for parenthood in 100 two-mother lesbian families compared to 100 heterosexual families. The author found that the desire to have children was stronger in lesbian women and that they gave more thought to the idea of having children.14 Gay males give the same reasons for parenthood that heterosexual males do; that is, the desire to nurture children, to have the constancy of children in their lives, and to achieve the sense of family that children provide.15,16

The health and well-being of the children of lesbian women conceived through ART has been described in several studies. Researchers found no differences between children raised by lesbian mothers and those raised by heterosexual mothers in terms of gender identity, behavioral development, and psychological development.11,17–21 A recent study, the first based on a national sample, compared 44 adolescents in lesbian families and 44 adolescents living in heterosexual families and found no significant differences between subjects on psychosocial adjustment, school outcomes, and romantic relationships.22 Adult offspring of lesbians were studied as well. Young adults between ages 17 and 35 who had been conceived in a heterosexual relationship but raised in a lesbian household were found to have healthy peer relations, to be psychologically stable, and to be no more likely to report same-sex attraction than offspring of heterosexual mothers.23 Though an estimated 6 to 14 million children in the United States live with at least one gay or lesbian parent, children of gay men have not been as thoroughly studied as those of lesbian women.12 For example, in a recent review of 23 empirical studies of children of gay and lesbian parents published between 1978 and 2000 only three studied gay fathers.24

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