Ethical Issues in Reproductive Technology: A clinician’s perspective

1. Ethical Issues in Reproductive Technology:A clinician’s perspective Dr. So, Wai Ki William Specialist in Reproductive Medicine

2. Dr. Patrick Steptoe Professor Bob Edwards

3. Louise Brown (1978 - , the world’s 1st IVF baby)  30 years on Louise Brown & family

4. The birth of a baby cannot be a crime!

5. procreation: a private act Procreative Liberty • full autonomy on the decision either to have or not to have children • “men and women of full age, without any limitation due to race, nationality or religion, have the right to marry and to found a family ” The United Nations Universal Declaration of Human Rights 1948

6. How has this become an issue? • Reproductive technologies permit procreation in manners that will not be possible by sexual intercourse and in manners hitherto unimaginable. • a child can come from • parents who have never met (donor gametes), • a parent who died years in the past (posthumous use of gametes or embryos), • a pregnancy of his grandmother (postmenopausal pregnancy), or • indeed a woman unrelated to him/her genetically (surrogacy).

7. How has this become an issue? • A most peculiar branch of medicine  the treatment of infertility calls for the creation of another human being! • Reproductive technologies result in the creation and existence of human embryos in vitro • The creation of supernumerary embryos  the need to deal with “life-and-death” decisions about inchoate human beings

8. Ethics Issues • RT itself • Access to RT services • Financial • Marital status: single or homosexual couples • Child-rearing ability: desirable parents • Age • Multiple pregnancy & Selective Fetal Reduction

9. Objections to RT • interference with Nature or playing God • disregards the sanctity of every human life • violates the sanctity of marriage & the family • involvement of a third party • effects on human rights, social structure & health policy

10. Agent Surrogate mother married couple Service provider RT Arrangements

11. Principles of Biomedical Ethics • Beneficence • Non-maleficence • Autonomy of persons • Justice Beauchamp & Childress

12. How do these principles apply to RT treatments? • RT treatments are consistent with the ethical principles of beneficence and autonomy • Do they do any harm? • The question of justice

13. Beneficence • Relief of the suffering and sorrow of those afflicted with infertility, • Offering them a ray of hope and the possibility to enjoy the blessings of rearing (biologically related) children.

14. Infertility Hurts! • a crisis of the deepest kind • threatens one’s sense of self, one’s dream for the future and one’s relationship with others • feelings of anger, guilt, denial, blame, self-pity and jealousy predominate • loss of control • isolation from friends and relatives

15. Birthdays Graduation Wedding

16. Non-maleficence • minimize risk and harm to all parties concerned, especially taking into account of the “welfare of the (unborn) child • Congenital anomalies • Physical & psychological development • Multiple pregnancies

17. Justice and Equality • equitable access to the use and benefits of reproductive technologies • can one prohibit access by other persons? • Unmarried couples • Scarcity of resources • Absence of infertility (lesbians and single women) • Preservation of fertility

18. Child-rearing ability &provision of RT services • Welfare of the child • Procreative right of infertile persons • Autonomy of service providers

19. Welfare of the child Parents who • are psychologically unstable • abuse drugs • have a record of violence to family members

20. Procreative rights Fertile persons (reproduce coitally)  • no systematic screening of their ability or competency to rear children • such actions not considered to be appropriate Why should infertile persons be denied services merely because they are infertile?

21. Autonomy of service providers • Treatment of infertility calls for the creation of a child (human being) • Physicians have a moral responsibility for the situation of the resulting child and may choose not to help bring about such an outcome • On the other hand, physicians have a moral obligation to help persons in need

22. Respect for Autonomy I From a moral perspective, the acceptability of the “normal” desire to procreate is constrained by a number of factors : • transmission of a serious disease to the offspring, • unwillingness to provide decent prenatal care,

23. Respect for Autonomy II • inability to rear children, • procreation will engender massive identity problems or other serious impediments to normal psychological development for the offspring so created, and • strain on scarce resources of the community.

24. Iatrogenic Multiple Pregnancies • Oocyte recoveries  27.3% twin deliveries & 3.4% delivery of triplets or more in 1998 worldwide • Since 1970, triplet deliveries have increased 3 – 5-fold and twins, 30 – 50% • Preterm, SGA and perinatal mortality • Long-term consequences  neuro-developmental disorders

25. Prospective parents’ autonomy • consider higher-order pregnancy as a positive outcome • underestimate the difficulty of raising multiples • the emotional stress of the infertility and the strong desire for a child • financial context  maximize the “benefit”

26. Physician’s autonomy • responsible for the implications of his actions for the mother and the unborn child(ren) • Moral obligation to cancel the cycle • or to restrict the number of embryos replaced

27. Justice in IMP • Financial pressure  less well off couples are forced to accept the risk of multiple pregnancy • Possible solution: public subsidies for ART

28. Non-maleficence • Not to cause unnecessary harm both to the mother and the future children • Moral responsibility to reduce the number of multiple pregnancies above the increase in pregnancy (success) rate

29. Selective Fetal Reduction (SFR) • The explicit intention is not to terminate the pregnancy but to improve the chance of survival of the remaining fetuses (cf abortion) • Decision psychologically and morally demanding  infertile couples value all embryos/fetuses

30. Other issues • Embryo cryopreservation • Family members as gamete donors and surrogates • Fertility treatment when the prognosis is futile (0 or ≤ 1%) • Preservation of fertility • HIV

31. Gracias Thank you 多謝 謝謝 Dankeschön Merci Thank you grazie