Ethics in Reproductive Medicine Research Paper

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In reproductive medicine a variety of diagnostic methods are used to discover causes of involuntary human infertility. Diseases in this area can be treated by a number of techniques, ranging in complexity from the simple and inexpensive to the highly sophisticated and expensive (Reiss 1998). The diagnostic methods used include both the invasive, such as laparoscopy, and the noninvasive, such as ultrasonography. They may be specific, in the sense that they give the answer to a question posed, or nonspecific, providing information that has not been asked for. Some diagnostic tests are quick, while others take longer, since they have to be processed in laboratories. The development of a variety of more or less effective approaches to involuntary human infertility, as well as the separation of human reproduction from sexuality, raises a number of ethical problems, discussed in books, journals, and the mass media (Shenfield and Sureau 1997).

1. Ethical Controversies

Cloning has recently been the subject of debate in many countries. There are different kinds of cloning, but the World Health Organization (WHO) and the Council of Europe have banned the cloning of human fertilized eggs for reproductive purposes. The objections to cloning, apart from safety issues, concern the identity and individuality of human beings. Nature produces identical twins, but many people argue that cloning of human beings will undermine the respect of the human being by making its identity and individuality subject to human ingenuity.

Current ethical issues include the disposal of frozen embryos (how and under what conditions this may take place), and posthumous treatment, much discussed in the UK in the late 1990s. Other controversies are raised by third party gamete donation and sperm cryopreservation, particularly concerning payment of donors, anonymity of donors, and selection of donors and recipients (discussed in, e.g., Council of Europe 1996). The different methods used in reproductive medicine raise different ethical problems, and hence need to be considered separately. The issues of oocyte cryopreservation, and reproductive tissue freezing (ovaries and testis), also raise issues of safety and consent—particularly for young people affected by cancer.

For example, assisted insemination using the semen of the husband or designated partner raises a somewhat different problem from that of assisted insemination using the semen of a third party. The need for careful counseling is important in both cases, but the status of the child, its right to know its biological father, needs to be considered in detail when a third party is involved. When semen is frozen, safety issues need to be considered, in addition to how long the semen may be stored as well as under what conditions and for what purposes it may be used. When semen banks are established, regulation is needed. If and when the semen is tested or manipulated, further problems arise.

At present, at the beginning of the twenty-first century, preimplantation diagnosis is limited to sorting out fertilized eggs carrying genes associated with severe diseases for which there is currently no cure, like Huntington’s chorea and certain X-linked diseases. Concern has been expressed that the practice may be extended to diseases which are less serious. Obviously, there is a sliding scale between more or less serious and also room for subjective differences in this grading of diseases. There is thus a risk of a slippery slope in this area (Shenfield 1997).

A fundamental issue concerns the moral and philosophical status of the fertilized egg and to what sort of protection it is entitled (Steinbock 1992, Hermeren 1993). The status of the embryo is crucial in many debates of the ethical dilemmas of reproductive medicine. Other basic concerns include the partly culturedependent reasons for reproduction.

2. A Framework For Analysis

The underlying values in the debates on dilemmas in reproductive ethics can be described in different ways, in terms of the rights and interests of the various stakeholders concerned, or in terms of duties towards patients and the future child. These duties may clash with each other as well as with the interests and rights of other parties. To make the underlying values and value conflicts explicit is to take a first step towards a rational discussion of these dilemmas.

An ethical problem arises in a situation where: (a) there are two or more possible courses of action; (b) one course of action satisfies or is compatible with certain interests, rights, or values, and another course of action satisfies others; and (c) all parties or all interests, rights, or values cannot be satisfied at the same time by one possible action. This is particularly the case if (c) is intensified in such a way that both options are incompatible with each other or if the values, which are included within the options, are conflicting with each other. Whatever alternative is chosen, there will be winners and losers. This is clearly illustrated by some of the well-known dilemmas in reproductive medicine, where the stakeholders (or parties involved) include the woman or the couple, present and future children, doctors and clinics, researchers, the pharmaceutical industry, taxpayers, and society at large.

3. Terminological, Empirical, And Value Issues

If a rational discussion of these ethical dilemmas is wanted, it is necessary to separate conceptual, empirical, and normative issues, as illustrated by the controversies over when life begins and the proposed distinction between embryo and pre-embryo (Jones and Schrader 1989).

Evaluation of criteria of success like ‘take-home baby rate’ also involves issues of all three kinds. Moreover, whether certain methods would harm children and parents or alter people’s understanding of themselves or of the act of procreation are empirical issues that people may disagree about, even if they agree on the goals of reproductive medicine. To be able to substantiate these empirical claims it would be necessary to proceed with long-term follow-up studies of children produced with the help of the various reproductive technologies available.

The utilitarian principle of maximizing the utility or achieving the greatest good for the greatest number of people is open to many interpretations, some of which will clash with Kantian principles that each person should be treated as an end in itself and not as a means to an end. They may also clash with rights-based theories of the sort advocated by Dworkin (1977). This is particularly evident in the debate over research on embryos and the conditions for destruction of spare embryos. Here respect for the autonomy of the gametes providers, by requiring their joint consent, may yield different conclusions than a utilitarian starting point would do. According to the latter, the consent of the gametes providers may be disregarded if it can be shown that using the spare embryos for research or for donation will maximize the greatest good in society. Whereas Swedish legislation requires that sperm donors be willing to reveal their identity to the child when he or she is grown up, if the child wants to know, French legislation requires anonymity (Shenfield 1997). These different requirements may have an effect on the number and kind of people willing to donate sperm. Interestingly, both requirements can be justified by considerations based on the welfare of the future child. Thus, there is a common agreement on the goal but different views about the best way to achieve it.

These differences could clearly be solved in principle by empirical research, involving long-term longitudinal follow-up studies in both countries of children who are the result of sperm donation. But these studies themselves raise further ethical problems. As the children reach a mature age, it becomes increasingly difficult to carry out the follow-up without their informed consent. How is this to be obtained in a country which makes anonymity compulsory? And can it be obtained without risk of harming or stigmatizing the children?

4. Goals

It may be helpful to distinguish between questions concerning the ethical acceptability or legitimacy of certain goals of reproductive medicine, such as the improvement of success rates in in vitro fertilization (IVF), and the ethical acceptability of certain methods used to achieve these goals. As indicated above, it is possible to agree on the goals and differ on the methods, and vice versa.

Do the techniques mentioned above help to achieve the goals of reproductive medicine? Do they help to achieve other goals as well?

If the goal of reproductive medicine is to cure diseases, it becomes necessary to clarify what is meant by a disease to understand this goal. If a particular condition is regarded as a disease, it falls within the goals of reproductive medicine to cure it; if not, it does not.

A fundamental issue is whether involuntary infertility is a disease, the result of a disease or a socially constructed need. This is not just a matter of semantic definition, since the different ways of regarding human infertility have social and economic consequences. If it is a disease, those suffering from it are entitled to help from the national or publicly funded health care system, whose resources should be used. Moreover, if infertility is a disease or a response to a disease rather than a social need, a case for financial support of the new reproductive technologies can also be made, as well as for research on such technologies. If, however, it is a socially constructed need, the case for financial support is much weaker.

5. Means

The methods available to achieve the goals of reproductive medicine vary, and new methods are being tested. Owing to breakthroughs in molecular biology, development is rapid (Fauser 1999, Harris and Holm 1998). Some methods, like surrogacy, have been criticized because they lend themselves to commercial exploitation and to seeing children as commodities, as ‘made’ rather than ‘begotten’ (O’Donovan 1984).

If and when the methods of reproductive medicine involve or presuppose preimplantatory or prenatal diagnostics, further issues are raised. The case for preimplantatory diagnostics in connection with IVF is that it can be used to avoid X-linked diseases such as hemophilia or certain forms of dystrophy. However, concerns are raised over the possibility that, for instance, indications may be expanded, and that they may be misused for eugenic purposes. Hence regulations or guidelines are necessary, and have been proposed in many countries.

Sex selection for social and economic purposes is practiced in many countries, like India and China. If there are normally about 105 girls born to 100 boys, population statistics indicate that perhaps 100 million girls are ‘missing’ in the world because of sex selection. The status of women in the world is subject to many cultural differences, and the most important arguments against sex selection focus on the equality of the sexes, emphasizing that gender is not a disease (Shenfield 1994). Suppose, however, that there is no social security for parents when they reach old age. Moreover, suppose that parents have to pay an expensive dowry for their girls, and that girls are not able to make a living by working outside of the home. Then the much-criticized practice of sex selection could be viewed as a culturally chosen means to achieve a certain goal (economic and social safety for the parents). This obviously further suggests that in order to abandon this practice of sex selection, alternative means of reaching this goal have to be made available. Since this may take considerable time, compromise positions have been suggested.

Further concerns have been expressed that, because some of the technologies used in reproductive medicine are expensive they will only be available for rich people in the industrialized parts of the world. They will thus help to increase the gap between the health care and quality of life available for the rich and that for the poor or, more generally, the gap between rich and poor countries.

6. Some Important Arguments

As already mentioned, the basic ethical dilemmas of reproductive medicine involve conflicts of interests, rights, or values. The first step in the attempt at a rational discussion of these conflicts is to make the conflicting interests, rights or values explicit, and to try to separate normative and empirical issues. This is sometimes easier said than done, because, for example, in the discussion of the importance of a genetic relation between parents and children all these issues are intertwined in a complicated way. Various arguments are used in discussing these conflicts. One rarely takes a stand on the basis of one argument or principle only—often several arguments or principles are used. Sometimes those advocating different positions use the same arguments or principles, but rank the importance of the arguments differently. The central arguments seem to be the following ones: the autonomy argument, the non-maleficence argument (an argument based on the principle that one should not harm), and justice arguments of various kinds.

6.1 Arguments Of Autonomy

These are derived from a position that attaches great weight to individuality and liberty. The principle of autonomy is the basis of the requirement of informed consent. If the technologies used involve risks, the principle of autonomy requires careful counseling of the candidate couples. If great importance is attached to this principle, it may overrule also the concern over commodification of human beings, their bodies, and their bodily products. If people have a right to do what they want, they also have a right to serve as surrogate mothers, to earn money on their bodies, and to sell their organs or bodily products. The problem of the limits of autonomy then becomes an important issue. This is also an issue of power: who is to set the limits, and in accordance to what other principles?

6.2 Nonmaleficence Arguments

Arguments based on the principle that one should not harm are clearly legitimate and have a long history in medical ethics (‘primum est non nocere,’ a principle known already in antiquity). It has been claimed that children who grow up in nontraditional families (for example, with two parents of the same sex) or are the result of particular reproduction technologies will suffer, because they lack role models of both sexes or because their intellectual or emotional development will be impaired. At present, though, the evidence supporting this or the opposite position is missing, or at best inconclusive.

6.3 Arguments Of Justice

Arguments based on the just distribution of scarce resources are also relevant. Clearly the resources for health care are not unlimited in any country, and there is always the problem of the fair use of these limited resources. Is the unequal access to treatment also unfair? If fewer than half of those who ask for it obtain assisted treatment by IVF, the reasons why some obtain treatment and others not take on an ethical significance (Shenfield 1997). Is this a case of discrimination on the basis of economic, social, or ethnic grounds or not? Moreover, the practice in different counties as to how many cycles are subsidized is also relevant here, since incomes are unevenly distributed. For some, a fee of EUR.10 000 is a small sum, but to others it is an effective barrier.

Fair access is clearly also a legitimate concern. If the available resources are to be used in an equitable way, and used to benefit those who suffer most, rather than to benefit those who are willing and able to pay, it has to be demonstrated that the methods are cost-effective. Though doctors should respect the autonomy of those who come to seek their help, doctors are not under any obligation, legal or moral, to provide patients with any treatment they might request (McCullough and Chervenak 1994). The request has to be compatible with good professional standards. The proposed treatment might be not benefit the patients or it might be incompatible with the interests of the child.

A related question that has been the subject of heated discussions is who should have access to the benefits provided by some of these reproduction technologies. Should IVF be available for single people, or for homosexual or lesbian couples? Should HIV couples or couples where one of the partners is HIV positive be entitled to treatment with artificial reproduction? Are there any age limits? Are any age limits appropriate and ethically justifiable? If the answer is yes, what sort of inquiries are appropriate before proceeding? In short, on what ground, if any, should some people be denied the access to these techniques?

7. Research Ethics

Here one set of problems focuses on the ethical acceptability of research on embryos in vitro, and another on the conditions of such research, if acceptable. According to the views of the Roman Catholic Church, neither such research nor IVF is morally acceptable. Embryo research is also explicitly illegal in some countries, such as Norway, and in practice illegal in others, such as Germany.

If, however, research on embryos in vitro is morally accepted, a number of more specific questions have to be asked and answered. They include what kind of research should be permitted, questions about the source of the embryos and for how long may embryos be used for research (14 days is a limit in many countries, like Sweden). Moreover, conditions have been laid down concerning the length of time frozen embryos may be saved and how spare embryos may be destroyed. All these issues are controversial, as is the question of whether embryos may be created solely for the purpose of research. The latter is explicitly forbidden in French legislation and in the Council of Europe Convention on Human rights and Bio- medicine (1996). The fundamental issue here concerns the philosophical and moral status of the embryo.

The human embryo deserves ‘respect,’ but a much contested question is what precisely this respect allows and what it forbids. The practice of research on embryos is subjected to strict regulations, as is experimental research on human beings. Informed consent by the male and female providers of gametes is a cornerstone in these regulations. The knowledge sought must be impossible to achieve in other ways, for instance, by research on animals. Further, this knowledge has to be of vital interest to present and future patients. Others regulations concern safety issues, in particular the safety of the applications of research.

Research on new reproduction technologies (diagnostic methods or treatment options) involves the standard issues of providing patients and healthy volunteers with information they understand and which enables them to make autonomous choices. Obtaining consent from research subjects who have deficiencies in understanding poses other difficulties. In this area of medicine, specific problems include that the fact the embryo and the future child are stakeholders, or parties concerned, but for obvious reasons, they cannot be heard. Someone, therefore, has to look after their interests. Often the parents do this, but sometimes they disagree. Who is then to look after the interests of the embryo or the child-to-be? Moreover, the women or couples seeking help may be under emotional or economic pressure, which will not aid rational decision making.

Yet another problem is over the safety of the woman or the embryo. Some of the methods used in research may involve physical, psychological, or economic risks. Protection against possible harm is a requirement for research—there always has to be a reasonable balance between the anticipated benefits of research and foreseeable harm to research subjects. If unexpected harm arises, however, measures have been taken to interrupt the study and to compensate the research subjects.

When sperm or human tissues are taken from tissue banks or sperm banks for research purposes, special problems have to be dealt with. The conditions under which such research may be performed have been regulated in many countries like the US, Sweden, and the UK.

Finally, there is the problem of fair access to research results, as well as controversies over payment or compensation to research subjects.

Bibliography:

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