Ethical Issues in Reproductive Technology: A clinician

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Ethical Issues in Reproductive TechnologyA
clinicians perspective

• Dr. So, Wai Ki William
• Specialist in Reproductive Medicine

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Dr. Patrick Steptoe
Professor Bob Edwards
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Louise Brown (1978 - , the worlds 1st IVF
baby) ? 30 years on
Louise Brown family
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• The birth of a baby cannot be a crime!

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Procreative Liberty

• full autonomy on the decision either to have or
  not to have children
• men and women of full age, without any
  limitation due to race, nationality or religion,
  have the right to marry and to found a family
• The United Nations
• Universal Declaration of
• Human Rights 1948

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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).

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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

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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

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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

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RT Arrangements
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Principles of Biomedical Ethics

• Beneficence
• Non-maleficence
• Autonomy of persons
• Justice
• Beauchamp Childress

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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

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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.

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Infertility Hurts! ?

• a crisis of the deepest kind
• threatens ones sense of self, ones dream for
  the future and ones relationship with others
• feelings of anger, guilt, denial, blame,
  self-pity and jealousy predominate
• loss of control
• isolation from friends and relatives

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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

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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

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Child-rearing ability provision of RT services

• Welfare of the child
• Procreative right of infertile persons
• Autonomy of service providers

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Welfare of the child

• Parents who
• are psychologically unstable
• abuse drugs
• have a record of violence to family members

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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?

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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

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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,

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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.

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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

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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

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Physicians 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

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Justice in IMP

• Financial pressure ? less well off couples are
  forced to accept the risk of multiple pregnancy
• Possible solution public subsidies for ART

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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

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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

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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

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Gracias
Thank you
??
??
Danke schön
Merci
Thank you
grazie