J. Blackmon

 Introduction  The Debate over RTs  Areas for Ethical Debate

Terminology and Concepts  Reproductive Technology (RT): techniques which artificially assist reproduction.  In Vitro Fertilization (IVF): Eggs are collected from the woman and mixed in a petri dish with sperm. Upon fertilization, embryos are placed in the uterus to establish pregnancy.  Intracytoplasmic Sperm Injection (ICSI): A single sperm is injected into an egg.

Terminology and Concepts  Preimplantation Genetic Diagnosis (PGD): After fertilization and before implantation, embryos are tested for presence or absence of genes or chromosomes linked to various medical conditions.  Pronatalism: An attitude or policy that encourages reproduction and promotes the role of parenthood.

1978, first IVF baby born: Moral Outrage  Playing God: Only God should bring a human life into the world.  Roman Catholicism: IVF is wrong for two reasons.  IVF deviates from normal intercourse, separating the unitive and procreative aspects.  IVF introduces a third person, defiling the sanctity of marriage and family.  Public opinion of RT is of course relevant to whether it will be allowed, funded, or otherwise supported.

Should we help the infertile?  What is infertility?  A disease?  A social problem?  Something else?

Infertility is a disease.

 Then RTs help the infertile function as healthy individuals.  This would be supported by a wide definition of health: “a complete sense of wellbeing”. (WHO)  Disease is something which detracts from that “complete sense of wellbeing”.  Thus, infertility, insofar as it detracts from one’s complete sense of wellbeing, is a disease and should be a part of health care provision.

Infertility is a disease.  An initial problem with the wide definition of health as “a complete sense of wellbeing”.  Construction noise next door might interfere with your yoga, but is there really a disease here?  The wide definition seems too wide.

Infertility is a disease.  Then RTs help the infertile function as healthy individuals.  This would be supported by a wide definition of health: “a complete sense of wellbeing”. (WHO)  Disease is something which detracts from that “complete sense of wellbeing”.  Thus, infertility, insofar as it detracts from one’s complete sense of wellbeing, is a disease and should be a part of health care provision.

Infertility is a disease.  Objection: Infertility has no single central cause; there is no specific condition to be cured. For this reason there is no single form of treatment.  Reply: So what? Diabetes, for example, has multiple forms of treatment. Instead of curing it, we manage its unpleasant effects. So, by parallel reasoning, we can manage the effect of infertility whatever its cause.  Frith is rejecting the idea we must have a single central cause.

Infertility is a disease.  Professor Edwards holds that genetic pressures incline us to want to reproduce.  Thus, having children is one of our basic natural needs—not a social construct.  If so, then infertility is a deprivation of a basic natural need.

Infertility is a social problem.

 On this view, there is no prima facie warrant to make fertility a central aspect of health care provision.  Wanting to become fertile is like wanting to become taller.  Maybe instead you need counseling.  Or maybe the best way of addressing infertility is to correct the biases in society which promote pronatalism.  Consider parallels with other biological features.

The Right to Reproduce

 Typically, the right to reproduction has been construed as a negative right.  Negative Right to X: The right not to have X interfered with against one’s will.  Positive Right to X: The right to have X made available to one.

Why were we talking about billboards?  What one person might call a negative right to X might be considered a negative right to not-X by someone else.  Do we have the right not to have to look at billboards?  Do we have the right to put up billboards?

The Right to Reproduce  Typically, the right to reproduction has been construed as a negative right.  If the right to reproduction is negative, then this protects the fertile from compulsory sterilization, but the infertile need assistance in order to become fertile.  So, reproduction must be understood in a positive sense, if it is to be protected as a right.

The Right to Reproduce  John Robertson (1994): Procreative liberty is the freedom to decide whether or not to reproduce. Someone has a right to something if it is required for procreation. Thus, we have the right to RTs. [66]  This effectively turns the negative right to reproduce into a positive right: Once infertility is understood as standing in your way of the right to decided whether to reproduce, and an RT is understood as providing a requirement for reproduction, you have a positive right to that RT.

The Right to Reproduce  Procreative Autonomy (PA): Personal reproductive decisions should be free from interference unless they will cause serious harm to others.  For example, Julian Savulescu promotes PA.

The Right to Reproduce  Some feminists have replied (to the advocacy of RTs as enabling PA) that RTs comes with their own pressures, and that women do not freely choose as a result.  Women are pressured by society, partners, and family to make use of RTs. Thus, on this view, RTs actually influence and constrain choice.

 Regulation of RTs  Treatment of Embryos  Donation of Gametes  Social Egg Freezing

Regulation of RTs  In the US there is no overarching framework; states and regulatory guidelines direct policy.  The ASRM considered further regulation in 2009, but reported that because RTs are “one of the most highly regulated of all medical practices in the United States”, no further regulation was needed.  We currently have a regulatory system that Frith describes as consisting of three levels, involving multiple agencies and various degrees of power.

Regulation of RTs The Dilemma of Multiple Embryo Transfer  In many cases, transferring multiple embryos significantly increases the probability of a successful pregnancy.  However, it also significantly increases the probability of a multiple pregnancy, thus increasing the probability of pre-term births and consequent health risks to those babies.

Regulation of RTs Other Areas of Possible Regulation  Age Limits  Welfare of Child

Treatment of Embryos Typically, IVF produces many embryos and spare ones are frozen or used in future research.  How long should embryos be stored?  Who owns them in the event the parents die or part ways? Who decides what to do with them?  Consent agreements may help. But the technology is changing rapidly and unpredictably. How much help a consent form can provide is unclear.

Treatment of Embryos How should embryos be relinquished?  Frith sees a continuum with anonymous relinquishment at one end and conditional relinquishment at the other.

Treatment of Embryos How should embryos be relinquished?  Anonymous Relinquishment: As with gamete donation, the donors would have no role in deciding who the recipients can be. Recipients could get information about health and physical characteristics of the donors.  Conditional Relinquishment: Donors can vet and choose their recipients, and they can negotiate terms of information exchange, contact, and involvement in the child’s life.

Treatment of Embryos How should embryos be relinquished?  Is conditional relinquishment adoption ?  The ASRM argues this is a misleading term, for it implies that the embryo is a “fully entitled legal being”, and this, as ASRM argues, leads to “a series of procedures that are not appropriate.”  Frith argues that the question of relinquishment cannot be decided by the question of personhood. [71]

Donation of Gametes  Donor Anonymity  Paying Donors

Donation of Gametes Donor Anonymity  Does the donor offspring have a right to identifying information about their gamete donor?  Having this information is thought to be essential to a person’s wellbeing.  However, making it available creates a disincentive for many would-be donors.

Donation of Gametes Paying Donors  Paying people to donate gametes can create an inappropriate motivation, and it can exploit the poor who would be more susceptible to financial inducement.  However, forbidding payment to donors deprives them of a source of income.

Social Egg Freezing: Eggs can be frozen as ‘an insurance policy’ against age-related decline in fertility. In favor:  Reproductive autonomy  Gender Equality  Example in Cancer Treatment  More Practical than Embryo Freezing

Social Egg Freezing: Eggs can be frozen as ‘an insurance policy’ against age-related decline in fertility. Against:  Over-medicalizing  False Hope

 What is infertility: disease, social problem, or something else?  Should people be free to freeze gametes or embryos for possible later use in attempted pregnancy?  Is anyone disempowered by IVF or other RTs?  Should gamete donors be anonymous to any future children?  Should gamete donors be paid?