IVF and Surrogacy

IVF and Surrogacy PHL281Y Bioethics Summer 2005 University of Toronto Prof. Kirstin Borgerson Course Website: www.chass.utoronto.ca/~kirstin

Overview • …Genetic testing (Purdy)… • IVF • Definitions/distinctions • Singer (for) • Sherwin (against) • Selling the body & surrogacy • Definitions/distinctions • Baby M Case • Murray (~against) • Steinbock (~for)

Purdy: Genetic Testing and Reproduction • Huntington's Disease (HD): “a devastating, hereditary, degenerative brain disorder for which there is, at present, no effective treatment or cure. HD slowly diminishes the affected individual's ability to walk, think, talk and reason. Eventually, the person with HD becomes totally dependent upon others for his or her care. Huntington's Disease profoundly affects the lives of entire families -- emotionally, socially and economically… • Early symptoms: depression, mood swings, forgetfulness, clumsiness, involuntary twitching and lack of coordination • Later symptoms: concentration and short-term memory diminish and involuntary movements of the head, trunk and limbs increase. Walking, speaking and swallowing abilities deteriorate. Eventually the person is unable to care for him or herself. Death follows from complications such as choking, infection or heart failure”

Huntington’s Disease “HD typically begins in mid-life, between the ages of 30 and 45, though onset may occur as early as the age of 2. Children who develop the juvenile form of the disease rarely live to adulthood… HD affects males and females equally and crosses all ethnic and racial boundaries. Each child of a person with HD has a 50/50 chance of inheriting the fatal gene. Everyone who carries the gene will develop the disease. In 1993, the HD gene was isolated and a direct genetic test developed which can accurately determine whether a person carries the HD gene. The test cannot predict when symptoms will begin. However, in the absence of a cure, some individuals "at risk" elect not to take the test” (Huntington’s Disease Society of America (www.hdsa.org))

Reproductive Threshold • Moral Minimalism – “it is morally permissible to conceive individuals so long as we do not expect them to be so miserable that they wish they were dead” • Puts no demands on us • Not many people would want to live in a world where this was the prevailing standard • Doesn’t pay much attention to human well-being • Minimally Satisfying Lives – “we ought to try to provide every child with something like a minimally satisfying life” (523) • Minimally satisfying = many elements. Purdy focuses on ‘health normal for that culture’ (for this argument) • Huntington’s disease does not meet this standard (in virtually all societies) according to Purdy

Purdy’s Argument • We ought to provide every person with a minimally satisfying life [from Utilitarian or Contractarian moral theory] • People with HD* are unlikely to live a minimally satisfying life [empirical claim] • People currently living with HD are at high risk of passing on HD to their children • We ought to prohibit people currently living with HD from having genetically related children • People currently living with HD are morally obligated to prevent the conception of genetically related children (or test for and abort fetuses with HD) *Huntington’s disease is used here but may be replace by any other genetic disease that we know to be the cause of a life that is not minimally satisfying as defined by Purdy

Analysis • Objection: Right to reproduce • What reasons do we have for this right? • Love, companionship, shaping a new generation? • Reply: adoption, AI, egg donation, IVF, cloning • Immortality, mini-me? • Reply: narcissistic? false? • Objection: Right not to know • Defensible only when ignorance does not put others at serious risk • Implications?

Genetic Engineering • Treatment • Enhancement

Reproductive Technologies • Natural human reproduction = sexual intercourse, tubal fertilization, implantation in the uterus, and subsequent in utero gestation • Reproductive technologies replace one or more of these steps: • Artificial Insemination – often used to overcome male infertility (with original male’s sperm or with donor’s sperm). Also sometimes used as a form of positive eugenics. Can be used in conjunction with surrogacy to overcome female infertility. Replaces first step. • In Vitro Fertilization (IVF)– “fertilization in a glass”. Sperm and egg united in a petri dish, grown to eight-cell stage. Combined with embryo transfer. Replaces first two steps. • Future possibility of ectogenesis (artificial gestation) – artificial womb would replace final two steps • Note: development of PGD (preimplantation genetic diagnosis) allows couples at risk of transmitting genetic diseases who make use of IVF to test and discard affected embryos

In Vitro Fertilization (IVF) • Reproductive technologies such as IVF bring the embryo outside of the human body • ‘Test tube babies’ • Used most commonly by people with certain types of infertility (ex/ blocked fallopian tubes), and by couples who don’t want to pass on a genetic disease (ex/ MS, Huntington’s)

Arguments Against IVF (with objections - Singer) 1. IVF is unnatural • Modern medicine as a whole? (Ex/ prescription drugs, surgery, chemotherapy) • Using our intellect to overcome adversity 2. IVF is risky for the offspring • Rate of abnormality with IVF is similar to that with natural reproduction (slightly higher but within reasonable limits)

… 3. IVF separates the procreative and the conjugal aspects of marriage and so damages the marital relationship • IVF can actually strengthen marriage, as infertile couples will then be able to have a much wanted child 4. IVF is illicit because it involves masturbation • Even if a prohibition on masturbation for sexual pleasure could be defended, in this case masturbation is being used to strengthen the marriage bond and procreate & this would seem to warrant separate analysis

… 5. Adoption is a better solution to the problem of childlessness 6. IVF is an expensive luxury and the resources would be better spent elsewhere • These objections to IVF rely on the principle that we ought to find loving families for unwanted or orphaned children before creating additional children • Recall: Singer is the philosopher who made the argument about our moral obligations to those in absolute poverty (from the first lecture). • “We cannot demand more of infertile couples than we are ready to demand of ourselves. If fertile couples are free to have large families of their own rather than adopt destitute children from overseas, infertile couples must also be free to do what they can to have their own large families.” (537)

… 7. IVF allows increased male control over reproduction and hence threatens the status of women in the community • Women have been actively involved in developing IVF • IVF was developed in part because of the demands of infertile couples – often it is the woman who is most distressed • Even if ectogenesis is developed, this should be embraced as an expansion of women’s choices rather than as an expansion of male control; it could remove the final biological barrier to true equality • Note: also raised in Sherwin’s article

Women and IVF “What is the relationship between IVF and women’s oppression?” Sherwin argues that IVF is morally problematic because: 1. Patriarchal Social Conditioning: ‘Breeders’ • Why do couples have such a strong desire or ‘need’ for children of their own? Assumed to be a natural desire or need, but… • Women are socially conditioned to believe that they are only ‘true’ women if they bear children – the desire or ‘need’ for genetically related children is, at least in part, socially and culturally constructed • IVF only adds to the inescapability of this conditioning – it further entrenches these values • Objections?

Women and IVF 2. Decrease in Autonomy • When other opportunities for fulfillment, self-worth, intimacy, and accomplishment are not present in women’s lives (meaningful jobs and relationships/friendships, for example), having children becomes the one outlet for these desires. Providing yet another way for women to have children (while the social conditions under which women are employed in lower-paying and less satisfying jobs is unchanged) is problematic • IVF looks like an increase in reproductive autonomy but actually represents a decrease in reproductive autonomy if you take the context of these decisions seriously • Offering more choices does not always mean increasing autonomy • Examples: PAS/euthanasia and the elderly, Cochlear Implants, Prenatal Genetic Testing • Objections?

Women and IVF 3. Continued Medicalization of Pregnancy and Birth • Technologies applied to pregnancy and birth (scheduled doctor appointments throughout pregnancy, forceps, lab coats, masks, bright lights, labour timelines, episiotomies, caesareans, fetal heart monitors) • These controls have in the past often become coercive and contrary to the interests of women • Many recently proven ineffective in top quality studies • Increases outside control of women’s bodies • Shifts power away from the woman • Decreases autonomy and self-esteem • Objections?

Surrogacy • A method of assisted reproduction • “Surrogacy refers to an arrangement whereby a woman agrees to become pregnant for the purpose of gestating and giving birth to a child for others to raise. She may be the child's genetic mother or not, depending on the type of arrangement agreed to.” - Wikipedia • The surrogate may also be referred to as a ‘contract mother’ or ‘gestational carrier’ • Chosen by gay male couples, infertile couples, busy working couples…

Surrogacy Relationships • Commercial / Altruistic • Traditional Surrogacy – AI + gestation • Gestational Surrogacy – IVF + gestation • Parenthood: • Genetic • Guardian • Gestational (women)

Main Argument For Surrogacy • Autonomy • Increased choice and control • Option for couples who may have no other means of having children • Option of employment for women willing to be surrogates

SELLING: Car Hair Blood Sperm Egg Parts of organs (ex// liver, bone marrow) Organs (ex// kidney, lung) Baby Child Yourself (into slavery) RENTING/LEASING: Car Mental labour (workplace) Physical labour (workplace) Sexual organs (prostitution) Uterus (surrogacy) Selling Ourselves?

Slavery • “Surrogacy is like slavery in the absence of reciprocity, in the fact that one person becomes what Aristotle called an ‘animated tool’ of another, serving simply as a means to another’s end” (In Murray, 547)

Baby M • Appendix, case 40 (699) • 1985 Commercial Surrogacy Agreement • Baby M born March 1986 • Mary Beth Whitehead (married with 2 children already) – traditional surrogacy • William Stern – married to Elizabeth Stern (MS) • $10,000 – $1,000(>5 months) - $0 (<5 months) • MBW had emotional attachment to baby & didn’t want to give the baby up • MBW fled the state with the baby • Changed location and remained hidden for 4 months • Eventually discovered and baby was returned to the Sterns • Trial 1 – contract ruled to be valid, MBW’s parental rights were terminated, sole custody was awarded to William Stern, adoption by Elizabeth Stern was authorized • Trial 2 (New Jersey Supreme Court) • Declared contract invalid and unenforceable. • In the end, on grounds of best interests, custody awarded to Sterns • But Mary Beth Whitehead’s parental rights and visitation were restored • 4 main concerns of NJ Supreme Court:

New Jersey Supreme Court Concerns with Replies (Steinbock) • Surrogate is not in a position to make an informed decision to surrender her child (paternalism) • Surrogate may underestimate emotional and psychological distress of separation • Reply: not good grounds for limiting autonomy • Risk of psychosocial harm to the child • Reply: speculative • Commercial surrogacy contracts are tantamount to baby selling* • Commercial surrogacy contracts allow the rich to exploit the poor*

*2 Main Concerns with Surrogacy • Commercialization of children • Exploitation of women who act as surrogates

1. Commercialization Murray: • Family relationship • Nurturing, affection, trust, intimacy • Unconditional acceptance, unchosen obligations • Commercial relationship • Exchange of goods and services for money • Control, choice, personal preference • Contracts • What is the impact of allowing commercial relationships to enter the realm of the family?

Selling Children • Usually thought to be wrong because: • Children have intrinsic moral worth and as such cannot be bought or sold • Consequences for children would be bad OR (Murray’s proposal): 3. Decreases human flourishing – which is best achieved within stable loving families and in warm, caring (noncommercial) relationships

Murray • “Given the sort of creatures we humans are, our patterns of psychosocial development, our needs at different stages of our lives – given these facts, certain values, institutions, and practices support our mutual flourishing better than others. Specifically, the values of the marketplace are ill suited for nurturing the values, institutions, and practices that support the flourishing of children and adults within families.” (548) • Altruistic or gift surrogacy is acceptable as long as it is contributing to family values

Murray • Sperm ‘donors’ who are paid are really sperm ‘vendors’ • Egg ‘donors’/’vendors’ – but much riskier • Compensation just for time (approx. 56 hours)? Inconvenience? Risk? Egg?

2. Exploitation When one party takes advantage of another’s economic need to secure something for considerably less than its value • What is the price of a baby? • In paid surrogacy, something ‘priceless’ is received in exchange for a modest amount of money

Steinbock • Surrogacy is not intrinsically exploitative • It is just a matter of regulations and guidelines • Allow payment only for medical expenses (as in adoption) and with carefully structured contracts

Murray’s Slippery Slope Concerns • If we discuss bioethical issues only in terms of choice and control: • Cloning human embryos, then cloning human embryos, freezing them, and implanting them in someone else, then implanting an aborted fetus’s ovary, with its millions of yet-unripe eggs, into a woman’s body, so that she might become pregnant with that fetus’s ova (550) • Surrogacy for convenience?

Summary • IVF • Singer (for) • Sherwin (against) • Selling the body & surrogacy • Baby M Case • Murray (~against) • Steinbock (~for)

Looking Ahead… • Research Ethics • *ESSAY 2 DUE in tutorial this Wednesday*

Contact Prof. Kirstin Borgerson Room 359S Munk Centre Office Hours: Tuesday 3-5pm and by appointment Course Website: www.chass.utoronto.ca/~kirstin Email: kirstin@chass.utoronto.ca

IVF and Surrogacy