Medical Ethics and the New Reproductive Technologies

For the first time in history, as an outgrowth of in vitro fertilization technology and research, the three components of parenthood–the genetic, the gestational, and the nurturant– can be separated, so that the loss of one does not necessarily result in the loss of the others. For a man or woman who may not be able to conceive a child genetically connected to him or her, ovum donation or sperm donation offers the opportunity for gestation and parenting of a child genetically connected to half of the couple. For a woman unable to carry a pregnancy o term, gestational care may be the alternative of choice. For couples who cannot provide egg or sperm, but who wish to experience pregnancy, embryo adoption may be an alternative route to parenthood.

Reproductive choices are not made easily. As couples near the end of their biological options, most contemplate–if only for a split second– what it would be like not to be parents at all. If they decide that raising children is their primary goal, they begin to think about alternative routes to parenthood. The array of adoption and third party parenting options available challenges couples to examine the relative importance to them of gestational vs. genetic connections. Prospective parents must think carefully about what it would mean to them to be a parent without experiencing pregnancy, or a parent with no genetic connection to their child. Others contemplate what it would be like not to be parents at all…

The Separate Components of Parenthood: Ethical Considerations“Just because we can do something , should we do it?” This is a question that has plagued scientists in the last half of the twentieth century. The field of reproductive medicine in particular has faced this question– perhaps more than any other field. The array of parenting options afforded by reproductive technology is staggering. The development of in vitro fertilization has made it possible for one child to have as many as five different “parents”– an ovum donor, a sperm donor, a gestational carrier, and two adoptive (rearing) parents. Furthermore, cryopreservation of sperm and of embryos has enabled people to preserve their potential fertility almost indefinitely. Cryopreservation of embryos has even enabled posthumous motherhood to be possible. The new parenting paths–and configurations–raise a profoundly difficult and often disturbing ethical question: Is it in the best interest of children to be created and parented through third, fourth, or even fifth parties?The Right to Reproduce vs. the Rights/Best Interests of Children
Until recently, a couple’s right to procreate has rarely been questioned. However, because of the new reproductive technologies, the question has arisen about whether the right to procreate includes the right to procreate using available technology and/or donor gametes or a host uterus. Many experts in the field, including John Robertson, a U. S. attorney/ethicist specializing in the field of reproductive technology, argue for procreative liberty, asserting that since the United States
Constitution affords people the right to procreate coitally, it also gives individuals the right to procreate non-coitally. Robertson believes that having children satisfies basic biologic, social, and psychological drives for many people and that “noncoital reproduction should thus be constitutionally protected to the same extent as is coital reproduction, with the state having the burden of showing severe harm if the practice is unrestricted.”

Those who believe in procreative liberty would agree, however, that although the law gives people the right to reproduce, it does not give people the right to parent the children they reproduce if they are deemed unfit. Unfortunately there are many instances in which the State, acting in the best interest of a child, removes that child from its home because the child is determined to be at risk. Furthermore not everyone is eligible to become a parent through adoption. Several states have outlawed private adoptions and require parents to “pass” a homestudy conducted by a licensed social worker, before they can legally adopt a child. Thus the purpose of the law is to protect children from harm–both physical and psychological– and the duty of the State is to advocate for the welfare of children. The question here is whether or not someone should be advocating for the rights of children who are not yet born or conceived, and whether we can know –even prior to conception–whether a child will be psychologically harmed as a result of the circumstances of its conception or birth.

There is a great deal of controversy about whether caregivers–from physicians to mental health clinicians– have an obligation to act as gatekeepers for unborn children. Procreative libertarians argue that the role of providers is to offer the technology if it is medically appropriate, rather than to make judgements about who deserves to become a parent or about how children should be created. This group of caregivers believes steadfastly in patient autonomy,in each person’s right to chose whether and how to procreate. Others feel strongly that when individuals/couples ask for assistance in procreating, caregivers then have an obligation to protect the interests of children (even if they are not yet born or conceived). They argue that not to do so would be abdicating their responsibility and could even be a violation of beneficence (assuring good and avoiding harm) if the caregiver sincerely believes that harm may be done.

Another ethical question arises from the ability to separate genetic from gestational from rearing parenthood: Is it is moral to create children from donor gametes when there are already children in the world who have been born and who need homes? Elizabeth Bartholet, an attorney, adoptive mother, and author of Family Bonds : Adoption and the Politics of Parenting (Houghton Mifflin, 1993) is critical of the new reproductive technologies. She believes that ART clinics intentionally attempt to convince couples that reproduction in one form of another is inherently better than adoption and that families created from genetic ties (or partial genetic ties) are stronger and more desirable than those created by adoption. Bartholet argues that what she sees as objective counseling would surely steer more infertile couples away from technological means of reproduction to adoption. In fact many infertile couples do struggle with this issue. Longing for a gestational and/ or genetic (or partial genetic) connection to their offspring, yet aware that too many children in the world need good homes, many prospective parents wonder if this longing to reproduce should take precedence over the right of existing children to have loving homes.

As we will see in Chapter 7 (”Surrogacy”), the ability to separate genetic from gestational motherhood means that offspring can be born (and have been born) to women old enough to be grandmothers and greatgrandmothers and who are likely to die before their children reach adulthood. The use of anonymous sperm or egg donation means that children may have several half siblings that they do not know. Furthermore, the separation of genetic and gestational motherhood may mean that a couple who have donated frozen embryos has several biogenetic children who are being raised by different families, and who know nothing about each other’s existence. These are but some of the ethical and psycho-social dilemmas brought about by the new reproductive technologies–dilemmas that couples face as they consider their parenting and treatment options.

The Right To Information Regarding One’s Genetic Origins
The history of gamete donation in the United States began in the late 1800s. Dr. William Pancoast, who performed the first insemination of donor sperm, claims to have done it secretly, not ever telling his patient that she had been inseminated with a donor’s sperm, and not telling her husband until after the fact. Thus began a tradition of secrecy that most donor couples have practiced for almost a century– telling no one (neither the child, the child’s physician, nor the extended family, etc.) the circumstances of the conception. Anonymity– the condition whereby both donor and recipient couple consent to the process but are unknown (and unidentifiable) to each other– has occurred along with secrecy in donor insemination.

A third concept– privacy– is often confused with secrecy.Privacy refers to the fact that each of us has the right to establish boundaries between ourselves –or our families–and others. When we identify these boundaries we are not being secretive, but rather, we are saying that it is our basic human right to maintain some separateness from those around us. Hence, we are being neither dishonest nor deceptive nor withholding if we do not tell everybody, everything.

The Right to Procreate with Unknown Gametes
Although sperm donation has been occurring for over one hundred years, improved technology, resulting in the ability to separate gestational and genetic motherhood, has paved the way for ovum donation as well. Although few people in the medical and mental health fields have
openly questioned the moral acceptability of gamete donation, it does raise an important ethical question: Is it morally acceptable to bring a child into the world with an unknown genetic parent?

This issue may be more timely now because our understanding has deepened in recent years about the relative weight of nature versus nurture in determining who a person will ultimately become. Although scientists are not quite ready to map the human genome, more and more information about biological destiny is unfolding on an almost daily basis. Because we now understand that genetics plays a very large role–larger than previously thought– in providing a blueprint for adulthood, the ethics of bringing a child into the world with unknown genetic origins is more questionable today than it was in the past. The concern is whether it may be psychologically or medically harmful to a person to have no information–or little information–about his/her genetic make-up. On the other hand, to deny a would-be parent the right to chose to procreate with donor gametes threatens both the patient’s autonomy and his/her reproductive freedom.

The Right to Know the Truth About One’s Genetic Origins.
Knowing the truth about one’s genetic origins and conception isdifferent from having identifying information about one’s genetic parents. As long as the practice of anonymous sperm donation continues in this country and the laws surrounding it do not change, donor offspring will not have access to their donors. Although many sperm banks are currently providing extensive information to parents regarding their donor’s medical and psychological history, most couples using DI in this country are still choosing not to tell their children the truth about their origins. In recent years a large body of mental health professionals, including family therapists, have begun to question the ethics of secrecy regarding gamete donation. These clinicians believe that denying people essential information about their identity, especially when it includes their medical history, is morally unacceptable. Furthermore, they cite the literature that comes from family therapy– and from adoption– documenting the negative impact of family secrets on parents and children and on family systems (see Chapter 10, “Telling the Truth: Why, When and How to Do So”).

Separating the various components of parenthood means that individuals and couples can create children who may be deceived about their genetic make-up and possibly (in the case of surrogates or gestational carriers) about who gestated and gave birth to them. As with the previous ethical dilemma–the right to procreate with unknown gametes, questions arise about whether a patient’s autonomy– in this case the right to choose not to tell one’s offspring the truth– should take precedence over the possible harm done to that offspring if he or she goes through life being duped about his/her identity and conveying a false medical history.

Liberation vs. Exploitation of Women for Reproductive Purposes
Although there are many who believe that the new reproductive technologies are nothing short of miraculous and open up choices to women and to couples that would never have been possible, there are others who believe that they are a curse on families and upon women. Assisted
reproductive technology is not without medical side effects or risks (see Chapter 2, “In Vitro Fertilization and the ARTs”), and people who are desperate for children may not be in the best position to objectively evaluate these risks to themselves or to third parties. The separation of the various components of motherhood means that some women who are not the intended parents (ovum donors and/or surrogates or gestational carriers) are being subjected to these risks. Many argue that an infertile couple/woman has the right to chose a procedure that involves potential physical harm, but that it is morally unacceptable to subject a young, fertile woman to these same risks when she is not the intended parent. Furthermore financial incentives may be inducements to third parties to ignore these potential harms. Here we see examples of when concerns about autonomy and beneficence may collide.

A common worry among caregivers and couples opting for known ovum donation, surrogacy, or gestational care (via a friend or relative), is that the physical ordeal may produce short or long term side effects that are harmful. Careful counseling–both medical and psychological– of willing third parties, enables these collaborators to thoroughly consider the risks before deciding to proceed. And many argue that third parties, like infertility patients, are also entitled to autonomy when it comes to decisions regarding their bodies. Others argue, however, that there is always inherent coercion (financial or personal) for donors, surrogates, and carriers that cannot be dismissed and that amounts to exploitation.

If you found this article provocative or enlightening, you’ll love the book from which it was excerpted…Choosing Assisted Reproduction.

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