Transcript Lecture 1 - Viewpoint from a clinician

Ethical Issues in
Reproductive Technology:
A clinician’s perspective
Dr. So, Wai Ki William
Specialist in Reproductive Medicine
Dr. Patrick Steptoe
Professor Bob Edwards
Louise Brown
(1978 - , the
world’s 1st IVF
baby)
 30 years on
Louise Brown & family
• The birth of a baby
cannot be a crime!
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
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
Agent
Surrogate mother
married couple
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! 
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, selfpity and jealousy predominate
loss of control
isolation from friends and relatives
Birthdays
Graduation
Wedding
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  neurodevelopmental 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
Thank
you