About 10% of all couples who want to have children are unable to have them, and popular culture calls them "infertile" (H.M.G. 1984; 1986, OTA 1988). The range of techniques available to assist them to have children, if they are not able or willing to adopt a baby is reviewed by Shannon in this book. Physicians have developed methods to overcome infertility, with the motive of helping such couples have their own child. In some countries the assisted reproductive technologies such as in vitro fertilization (IVF) and donor insemination (DI) are involved in 1-2% of the live births. The birth of children to infertile couples brings not only great human joy but a new human being. It is consistent in theory with the ethical principles of autonomy and beneficence, often argued to be the premier ethical principles.
In regulation of these techniques, as discussed by Daniels in this book, society should recognize the frustration of couples who desire to have a family genetically related but are unable to achieve this on their own. In our society there are many prenatalistic ideas putting pressure on couples to have children, and there is a shortage of children for adoption (though this has not been aided by the racial selections in the procedure endorsed by some hospital boards). These medical treatments are the means of raising children for many couples who were not able to give birth to children. All methods for the procreation of children should always have the well being of the family in mind, so that we do not harm the children who result. In regulation of techniques, society has to avoid doing harm by excessive regulation and prohibition of techniques if that would do harm to the families that make up society.
To add to the ethical evaluation, assisted reproduction is also accompanied by questions of justice in the eligibility for access to the techniques. While the resources are limited, the first priority for government funding should be to benefit infertile married couples. For long-term de facto "married" couples, who wish to have a child by IVF, it would seem that they should be prepared to become legally married if they wish to use the involved procedures of IVF, and to raise children. But the question is whether, as is done in Germany, a state can prohibit access by other persons, including homosexual couples, and single parents (male or female). In the Netherlands lesbian couples have used IVF and AID. In the USA courts have ruled that it is not possible for clinics to refuse to consider applications for reproductive technology from unmarried couples, or single women. In the US Constitutional tradition, there is a right to procreate and raise children according to individual preferences. There are two levels of implication of the principle of justice, one is payment for services from government, which can be argued to be a matter of public consensus and policy. The other level is when a person pays from their own money, and here we have seen some countries allow single women and men pay for infertility services to bring about the birth of children that they will be social parents of, whether or not they are genetic or gestation parents.
Fertile people may have a need for infertility treatments also.
People who undergo radiation treatment, especially women, may
want to store eggs for use after. Some chemotherapy agents
also can cause mutations. Oocyte recovery would allow future pregnancy.
A women in the twenties may want to store oocytes produced then,
for implantation in the thirties when she wants to have a child,
as older women have increased risks of chromosomal abnormality.
Abnormalities can be screened for using genetic screening, but
oocyte recovery when there is a more significant risk of mutation,
and the case of possible absence of oocytes, is justifiable.
It is a question of resources available, more than anything else,
once we accept IVF as an ethical technique. Sperm banks can also
store sperm for future use also. Generally ethical concerns have
led most people to restrict posthumous use of gametes (Marshall,
1998).
Views of reproduction
There are several different views of ART we can have for ethics. The parents-to-be can consider it a right for reproduction, a duty to fulfil social obligation, a privilege to be able to bring about the creation of a child as a gift of God, a risk that the child will inherit a genetic disease or be harmed by environmental pollution, or a burden imposed by familial pressure to fulfil their duty. The creation of a child can be considered the ultimate act of love, and the parent-child relationship is arguably the central love relationship we can see among human relationships (Macer, 1998a).
Depending upon the view we have of the reproduction, we could arrive at quite different ethical conclusions. The right for reproductive chose comes from the principle of autonomy, whereas bringing about the birth of a child with a genetic disease has been considered as causing harm by some (review in Macer, 1990). Nowadays, many people consider it a right to use prenatal diagnosis, and also many consider it a duty for responsible parenthood that now extends into prenatal care (Macer, 1998b).
The children can view reproduction as a reason for existence itself. It is also the prime origin of their future happiness and sadness in life, bringing about their actual being as a moral person. Generally we can not regret our creation itself, though in extreme periods of depression people do regret that they exist. There is no reason to believe that children brought into the world by ART feel any more sad than children who came about in the non-assisted human reproduction between a man and woman. In fact, many children may feel that their parents had a greater desire that led them to seek ART. For a few exceptional cases, where ART is used as a preference over normal sexual intercourse, for example by lesbian mothers who refuse to have a sexual intercourse with a man, we can also question whether the act itself is central to the ethical conclusion. The consequences and the virtue (to want to bring about a child) arguments would both support the creation of a child.
Society can have various views on ART. Some societies actively seek to have more children, for example the state of Israel, and some other countries with strong religious and/or political goals for population increase. More often societies are actually trying to reduce population growth, so that countries like Italy or Japan tend to have negative population birth rates. Countries with strong population policies such as China, have also realized there is a need to maintain a reasonable population age structure of active workers to support both young and old persons. Justice questions make us consider the cost of the birth of babies by IVF, which in the USA in 1995 was on average US$39,000 (Goldfarb et al., 1996). There are also questions about whether young or old have more right to use the services (Parks, 1996).
With the trend to focus more on individual choice, society has
generally accepted the provision of services to help the infertile.
Infertility as defined in the first sentence of the paper, where
people desire to have a child, has been considered a disease in
the medical sense. Medical service providers may then view ART
as a service to help people who are in need (McCall, 1996). Some
providers also regard the services as a business, and make considerable
income through private services. We can see adverts for the services
offered by commercial agencies in countries around the world,
from USA to India.
Future extensions
As a result of IVF there are numerous spare eggs, and embryos. The ownership, and fate of these embryos is one of the major questions arising from the use of IVF. There are also many eggs that have been taken from women being sterilized, and increasingly they have donated the eggs for scientific research. These eggs can then be fertilized to provide a large supply of human embryos for scientific research (Davis, 1995). The goal of much embryo research in the past decades has aimed at successful alleviation of infertility, and has now led directly to the births of hundreds of thousands of children by IVF. The first experiments on early embryos were a necessary prerequisite to the technique of IVF (Steptoe, 1985; Freeman, 1996). The preimplantation embryos needed to be studied before being used clinically, especially the cell nuclei and chromosomes, to ensure that they were normal. Only after numerous studies of animal embryos were some human embryos studied to see their resistance to noxious agents, and manipulation that was needed for IVF.
Most patients undergoing IVF treatment around the world have embryos frozen, because as a medical technique, IVF is best used by taking many eggs in one operation (Edwards, 1989). These eggs are then frozen until needed. The procedure to remove eggs is complicated, and involves a period of hormonal stimulation of egg maturation, so it is easier, cheaper and less traumatic to take all the eggs that can be recovered (may be 20) at once. Clinics only need to replant 2-3 embryos to have a reasonable chance of a successful pregnancy. In fact a limit of two or three embryos implanted per cycle is enforced in some countries to lower the risks of multiple pregnancies. If it is unsuccessful, another set of embryos will be replanted at a later date. The overall increase in the efficiency of the IVF procedure due to freezing is about 15-20%. Experiments also led to ICSI, which is mechanical injection of sperm nuclei into the oocyte, or chemical or physical methods of fusing the egg and sperm membranes (Levinson et al., 1985). There have been safety concerns expressed over ICSI.
The production of any human/animal hybrids or chimeras should not pass beyond the stage where the primitive streak is formed, though in practice most would not survive beyond the 2-4 cell stage. The situation regarding chimeras of different human embryonic cells is unclear, but should only be used if it is going to be a therapeutic advantage to the individual made. It is possible that this situation could be reached in the future, though the technology for making chimeras has existed for several years.
We can't reject these techniques as "unnatural" because we would then be rejecting modern medicine as a whole, as every medical treatment is aimed to resist disease and suffering. There has been a concern about the capacity of technology to change, not just the conditions of human existence, but its essential characteristics (O'Donovan, 1984). What has occurred with reproductive technologies is a revolution in our view of human reproduction. The writings of thirty years ago were mainly against IVF, but now most writers see it as ethical for use by married couples (Macer, 1990). It is not a matter of being conformed to the world, but rather the value of hindsight and understanding upon a technology.
The religious objections to masturbation used in these treatments are used only by a few conservatives, most theologians do not consider this important. The motive behind the act of producing semen is procreative and so different to the acts that those claiming scriptural objection refer to. Religious taboos may be eased in the case of IVF, as it leads to cocreation of children. The sexual taboos should not have a role in the assessment of these issues unless they are morally relevant. We should note that IVF for married couples is accepted in some Islamic countries, where there are clinics. It is also accepted by many Jews (Grazi, 1994), and there are clinics in Israel, that will provide services to a broader group of infertile women. There is still objection to the separation of procreative and conjugal aspects of marriage, from the Roman Catholic (Vatican, 1987). The view of the Roman Catholic church has been that aids to infertility involve the intrusion of a third party, the physicians and scientists, into the marriage as a means of solving the infertility problem. This was seen as a trespasses upon the covenant and exclusive relationship between the husband and wife, who are "one flesh", and also intruding into the parent-child relationship of the family. The argument that children who are not born as a result of conjugal intercourse are deprived of "proper perfection" (Vatican 1987) has no scriptural, reasoned or scientific basis. This is not only an unscriptural doctrine but cruel, harmful and in my opinion a mistake which needs changing, as such statements affect the lives of many people, who look to religious authorities as sources of moral guidance. We can hope that theological interpretations consider new technology.
There have been feminist critiques and defenses of ART, as discussed by other authors in this book (also see, Basen et al., 1995; Liesen, 1995). One can ask whether infertility I a socially constructed disease unlike other diseases (Gibson, 1995). For Buddhist views and Japan see the paper by Shirai in this book, and for public opinion around Asia see results of the International Bioethics Survey by Macer (1994).
Besides the ethical argument that children should be able to know their roots, there are also medical reasons for regulation. This is especially so for semen donors, as there has been numerous accounts of the transmission of infectious diseases, such as HIV, ureaplasma, cytomegalovirus and herpes simplex virus. There is currently a lack of systematic screening of semen. In France there is some genetic screening of semen, and recipients, to avoid known serious genetic disease (Jalbert et al., 1989). The American Fertility Society (1990) guidelines recommend that each donor should be limited to 15 successful pregnancies, though less in smaller local areas. In South Africa the maximum number of children that one donor's sperm can be used for, is five.
It may be more balanced to use both egg and sperm from outside of the marriage, making the separation between genetic and social parenthood more fully. Donated embryos may be used, it is generally considered that any "spare" embryos made during the process of IVF, or donated egg and sperm, remain the property of the donors. The responsibility of safe medical practice is the responsibility of the medical staff. The doctor used to be the major selector of donors, but with the existence of large sperm banks the parents can increasingly chose the donor's characteristics, usually to match those of the husband or possibly with eugenic aims. There needs to be control over the number of times the same donor is used, so that there is a low chance of unwitting incestuous marriages. Some believe that the procedure is best left under the control of doctors, but it is very open to personal abuse.
There are commercial sperm banks operating in the USA, which has long been tolerated but is widely considered to be unethical. It is possible to separate both genetic and social parenthood from physiological parenthood, as in the case of womb-leasing, or surrogate mothers. There are laws in some countries including and some states of the United States, which say that if the surrogate decides to keep the baby than no contract that she has signed can prevent her doing so. Carrying a baby to birth is the primary legal right to being a parent of the baby. In other countries and states of the United States, the preconception intent of the parents governs who are the legal parents of the child born (Andrews, 1988). It is doubtful whether surrogacy should itself be illegal, as it seems strange to make the birth of a child illegal (Glover et al., 1989). However, it should still be discouraged from an ethical viewpoint.
There are psychological and emotional factors which require careful scrutiny. Surrogacy in terms of financial gain is morally wrong to most people. Surrogacy could lead to the situation where wealthy couples do not have to have the experience of pregnancy but let other women, who need money, have the troubles of pregnancy. There is a real danger that it would lead to the exploitation of poorer women. In the United States there are many surrogacy agencies, which involve commercial payments, and they offer services to clients from Japan and Germany for example, whose own countries do not allow surrogacy.
We have to consider the future of society in the genomic age. While we have got somewhat used to the genetic age, although few people understand it, the speed of development of genetic sequencing technology is so rapid, that the complete human genome sequence of three individuals is expected to be available by the end of the year 2000. On the 1st April 1999, Celera, the new company of Craig Venter started sequencing the human genome. Today we can go on the Internet to look at the complete genomic sequences of over 20 species. Celera will have a daily sequence capacity of 100 million base pairs a day. In this facility, the sequencing of the first bacterial genomes would take about two hours. They predict it will take 18 months to finish the genome sequences to make a composite human genome. Already Craig Venter and some other scientists are talking of individual genomic sequencing, and at least thousands of mutations can be screened simultaneously already.
It is clear that very soon this technology
will be common place, so that a person's ability for decision
making on genetic information will need to be improved. Therefore
when we read comments in reports or surveys like, "If I know
my child will have Alzheimer's genes, I will never have a child.",
we ask what people will do when they are given these choices as
part of routine health checks. In many countries there are regular
and efficient systems for public health checks through city offices,
but generally there is insufficient counseling for the tests that
are offered. This situation will just become worse. Some traditions
of selection in birth such as sex selection have been widely criticized,
because they are not for disease (Berkowitz and Snyder,
1998). However, the Genetics and IVF Institute in Virginia, USA
is offering parents sex preference choices since 1998.
Conclusions
Some of the key ethical questions that have been raised in this paper for society and cultures to consider include questions for:
Users
1. Should single parents have equal access to ART?
2. Should homosexual parents have equal access to ART?
3. Should we have age based discrimination against the young or old users?
4. Should an assessment be made of the stability of the relationship of the parent and family the child will enter?
5. Can we consider who are desirable parents?
6. Should users be compensated for costs to make access independent of income?
Donors
1. Should the donors of gametes or embryos be unknown or known before and after to the users?
2. Should the gametes be selected or not-selected, e.g. for genetic disease, race, intelligence, sex, desirability?
3. Should the donors be paid or unpaid?
4. How long should gametes and embryos be stored in banks, and what happens to left over embryos?
Embryos
1. How long should embryos be stored in freezing?
2. What is the fate of unused frozen embryos, research, donation or wastage?
3. Should genetic twins ever be gestated separately in different mothers or at different times?
Within each culture we can individuals who desire the use of ART, and may take different positions on these questions. As a general principle of ethics we should respect others, and have tolerance for the expressions of autonomy of other persons. However we should not allow harm of children, or the parents and users of ART. There is cultural diversity in the approaches to ART that have been set in law, however, in reality there is much more debate with society over the benefits and risks of IVF as shown by surveys (Macer, 1994). This diversity demands tolerance, and the birth of a child should never be a crime.
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