Reproductive Control: Ethical Questions & Technological Advances

1. Chapter 4: Reproductive Control

2. A Brave New World • Over the centuries we have steadily expanded our understanding of, and control over, many aspects of the natural world but one natural process that largely eluded our mastery has been our own reproduction. • But events in just the past few decades have changed that. Increased knowledge of reproductive biology and the development of sophisticated medical technologies now allow us to manipulate the human reproductive process in ways only dreamed of before.

3. Examples of reproductive innovations • We can remove an ovum from a woman’s body, fertilize it, and then, place it in her uterus so that it may develop into a child. • We can remove one or more of the cells of a growing embryo and allow them to develop into separate embryos. • We have learned to clone mammals, producing a genetically identical twin, which puts us now in position to clone ourselves.

4. Are we taking a dangerous moral step? • But, new advances can bring new questions. • A fundamental ethical question about the technology of human reproductive control is whether it ought to be employed at all. Is it simply wrong for us to use our knowledge of human biology to exercise power over the processes of human reproduction? • This question seems especially relevant to the prospect of human cloning, which has yet to be successfully accomplished. • The deliberate production of genetic clones of ourselves can seem like such a radical break from what we are accustomed to that to allow it happen would create a world where anything is morally permissible. So, perhaps we should not take that step.

5. What are the limits? • But, for some other forms of reproductive control, the cat is already out of the bag. • We already have sperm banks, donor ova, artificial insemination, frozen embryos, and surrogate pregnancies. • What ethical and legal limits, if any, should we put on their use?

6. Value of autonomy • Answering these questions can be especially contentious because reproductive decisions are intensely personal and represent a fundamental aspect of our autonomy. • If a technology becomes available that expands our ability to exercise that autonomy then any proposed restriction demands serious justification.

7. Impacts on others • On the other hand, reproductive decisions, even before recent technological advances, could have impacts on others, most notably children themselves, so autonomy is not the only factor relevant to the ethics of reproduction. • But the new technology has broadened the landscape of consequences creating new ethical dilemmas not possible before. • Some of those dilemmas are explored in this chapter.

8. Section 1: Assisted Reproduction and the Limits of Autonomy • For a variety of reasons, woman or couples, who want children, have had difficulties conceiving them. Since having children is among one of our most important values, allowing as many people as possible to achieve this goal seems worth encouraging. • (By some estimates, at least 5 million men are infertile, and one in nine married couples has difficulty conceiving a child.) • Assisted reproduction (AR) refers to the use of techniques, outside of ordinary intercourse, to increase the chances of conceiving a child.

9. Fertility drugs • One form of the technique attempts to improve the viability or number of either sperm or ovum through the use of a “fertility drug”. In the case of women, this has taken the form of giving her a reproductive hormone which causes her ova to ripen more quickly than they otherwise might thereby increasing the chance of pregnancy.

10. In Vitro Fertilization (IVF) • Another important technique, which uses the first, is in vitro fertilization (IVF). • Ordinary human fertilization takes place in utero (strictly speaking in the fallopian tubes) when a sperm cell unites with an ovum. In vitro fertilization is fertilization that is artificially performed outside the woman’s body—in a test tube, so to speak.

11. IVF • In IVF, the woman is given a reproductive hormone to cause her ova to ripen. Several mature eggs are extracted from the ovarian follicles and placed in a nutrient solution to which sperm is then added and where fertilization can take place. • Fertilized eggs are transferred to another nutrient solution where they undergo cell division. The embryo is then transferred to the woman, who has been given injections of hormones to prepare her uterus to receive it.

12. Limits of IVF • The chance of a woman’s becoming pregnant with the help of reproductive technology is roughly the same (by some estimates) as that of a normal, healthy couple attempting conception during the woman’s regular monthly cycle. • Almost three-quarters of the women treated in infertility programs never become pregnant.

13. Downside to artificial reproduction (AR) • While AR can potentially improve a couple’s chance of conceiving, the availability of AR has given rise to consequences of potential ethical concern. • AR is costly. Each fertilization cycle costs from $12,000 to $15,000, and most women who get pregnant go through three or four cycles before pregnancy occurs. This has given rise to a lucrative private market in providing fertility treatments and along with it questions about what guidelines fertility clinics need to follow.

14. Downside to AR • An increasing number of studies indicate that a child conceived by some reproductive technologies may be at risk for serious birth defects. • Fertility drugs can increase the chances that the women will become pregnant with multiple fetuses. This can result in miscarriage or put infants at risk.

15. Downside to AR • Also, even if a miscarriage doesn’t occur, a multiple pregnancy puts the infants at risk. Normal pregnancies last about forty weeks, but multiple pregnancies rarely go full term. Triplets are born around 33.5 weeks and quadruplets after 31 weeks. Because of their prematurity, babies born as multiples often suffer from such problems as blindness, stroke, brain damage, and impaired motor skills. • The costs of multiple pregnancies include a social cost, along with the personal costs of the mother or the parents. As many as 20% of the babies in some neonatal intensive care units are babies conceived by reproductive technology and born prematurely.

16. Ethical questions raised by AR • Should we allow women who become pregnant with multiple fetuses to try to carry them all to term? • Should we require that any woman who wants to use assisted reproductive techniques agree beforehand to a selective reduction (abortion) of some of the fetuses? • Fertility clinics can now violate the professional guidelines for limiting the chances of multiple pregnancy without suffering a legal penalty. Should those guidelines be given the force of law?

17. Reading: The Octomom and the Duties of the Fertility SpecialistsHo ward Minkoff and Jeffrey Ecker The authors use the controversy surrounding the birth of octuplets to NadyaSuleman (they don’t refer to her by name) as an occasion to address some of the criticisms of her reproductive endocrinologists (fertility specialists). The authors deal with three specific questions about the responsibilities of reproductive endocrinologists: (1) Should reproductive endocrinologists consider the economic interest of society? (2) Should they consider the parenting abilities of their potential patients? (3) Should the number of embryo transfers be limited?

18. Reading: The Octomom and the Duties of the Fertility SpecialistsHo ward Minkoff and Jeffrey Ecker • Minkoff and Ecker argue that the economic interest of society is not a concern of reproductive specialists, that in some cases they should refuse to provide reproductive help, and that there should be a limit on the number of embryos transferred.

19. Reading: “ Give Me Children or I Shall Die!” New Reproductive Technologies and Harm to ChildrenCynthia B. Cohen • Cohen points to evidence suggesting that the use of reproductive technologies produces serious deficits in a small number of children and asks whether, if this is so, it would be wrong to continue to use them. • Cohen focuses on the “Interest in Existing” argument, which holds that producing deficits wouldn’t necessarily be wrong because, except in extreme cases, it’s better to be alive than not exist.

20. Reading: “ Give Me Children or I Shall Die!” New Reproductive Technologies and Harm to ChildrenCynthia B. Cohen • A flaw in the argument, Cohen claims, is that it assumes children are waiting in a world of nonexistence, where they are worse off than if they were born. • A second flaw is that the argument justifies the use of technology to produce any harm in children, as long as it is not so bad as to make death preferable (produce a “wrongful life”).

21. Reading: “ Give Me Children or I Shall Die!” New Reproductive Technologies and Harm to ChildrenCynthia B. Cohen • Cohen argues that this is to view the nonexistence of not being born (which is neither good nor bad) as the same as the nonexistence produced by death (which may be preceded by devastating or serious deficits). • Cohen addresses the issue of what counts as a serious deficiency and claims such judgments must be made in specific circumstances in particular cultures. • She ends by considering how obligations to actual children differ from those to potential children and why potential parents must make informed choices about using reproductive technologies.

22. Reading: The Right to Lesbian ParenthoodGillian Hanscombe • The author sees the possibility of becoming a single parent as a major advantage of reproductive technology. • She argues that homosexual parents are entitled to the same treatment from physicians and institutions as heterosexual ones. • The objection that lesbian women should not be allowed to reproduce by artificial insemination is not one that can be supported by relevant evidence, Hanscombe claims.

23. Reading: The Right to Lesbian ParenthoodGillian Hanscombe • No studies have demonstrated that lesbian mothering is any different from heterosexual mothering or that children of lesbian mothers “fall victim to negative psychosexual developmental influences.” • She mentions instances of what she considers to be groundless prejudice against lesbian women by the medical establishment.

24. Instruction on Respect for Human Life in Its Origin and on the Dignity of Procreation: Replies to Certain Questions of the DayCongregation for the Doctrine of the Faith The document takes the position that a number of current or potential practices connected with reproductive technology are morally illegitimate. Included are the following: • The use of human genetic material in procedures like cloning, parthenogenesis, and twin fission (the splitting of gametes) • Attempts to manipulate genetic material for the purpose of sex selection or to promote desirable characteristics • Artificial insemination involving unmarried individuals or the artificial insemination of an unmarried woman or a widow, even if the sperm is that of her deceased husband.

25. Instruction on Respect for Human Life in Its Origin and on the Dignity of Procreation: Replies to Certain Questions of the DayCongregation for the Doctrine of the Faith • Acquiring sperm by means of masturbation • Surrogate motherhood Some techniques and practices, according to the document, are morally legitimate. Included are the following; • Medical intervention to remove the causes of infertility • The prescription of drugs to promote fertility

26. Instruction on Respect for Human Life in Its Origin and on the Dignity of Procreation: Replies to Certain Questions of the DayCongregation for the Doctrine of the Faith • The document also makes a number of specific recommendations to governments to establish laws and policies governing reproductive technologies. It asks that civil laws be passed to prohibit the donation of sperm or ova between unmarried people. • Laws should “expressly forbid” the use of living embryos for experimentation and protect them from mutilation and destruction. They should also prohibit “embryo banks, postmortem insemination and ‘surrogate motherhood.’”

27. Section 2: Savior Siblings • A savior sibling is a child conceived for the purpose of creating tissue (most often bone marrow) or an organ (a kidney) to potentially help save the life of an already existing sibling. • Savior siblings are sought in cases where it has proven difficult to find a suitable genetic match for the ailing child, among relatives or in tissue banks. • To increase the chances that the savior sibling is of the right match, the pregnancy might be produced through IVF. This will allow screening for those embryos with the right tissue type.

28. Section 2: Savior Siblings • The use of IVF raises ethical issues explored in section 1 of this chapter. • But even if the pregnancy is achieved through ordinary intercourse, ethical questions still can be raised: • In having one child to save another, aren’t the parents simply using the sibling savior as a “means” and not as a person with unique worth?

29. Section 2: Savior Siblings • Are we not also taking a giant step down the path that ultimately would lead to conceiving children merely to be sources of tissues and organs needed by others? • Finally, how will the sibling child herself feel once she learns that she was brought into the world just to help another person? Might knowing this be damaging to her sense of self-worth?

30. Reading: Should Selecting Saviour Siblings Be Banned?Sally Sheldon and Stephen Wilkinson • The authors review the case against using pre-implantation genetic diagnosis plus human leucocyte antigen (HLA) matching to choose an embryo that, when implanted, will develop into a child who can supply tissue to save the life of a brother or sister in need—hence the “saviour sibling” label. • The authors limit consideration to cases in which the tissue supplied is umbilical-cord tissue, not that of a vital organ. • Cord blood contains the blood-producing stem cells needed to replenish the bone marrow in patients with leukemia whose marrow is destroyed as part of their treatment. Bone-marrow transplants can also use marrow taken from compatible siblings, as well as others.

31. Section 3 Human Reproductive Cloning • Cloning produces individuals that are exact genetic copies of the donor from whom the DNA was obtained. • Several animals, including the famous sheep Dolly have been cloned (See the discussion of Dolly in Chapter 3). • In cloning, DNA is extracted from a somatic cell (S) of a developed organism. The DNA from an egg cell (E) is also removed and discarded. The DNA from S is inserted into E (which no longer has any DNA).

32. Section 3 Human Reproductive Cloning • The resulting embryo is implanted into a uterus and allowed to develop. If all goes well, an offspring will result which is genetically identical to the donor of somatic cell S. • Nothing in principle stands in the way of cloning a human, but so far this has not been done.

33. Section 3 Human Reproductive Cloning • However, a technique similar to cloning, called “twinning”, has already been used in connection with humans. • In 1993, Jerry Hall and Robert Stillman took seventeen two to eight-cell human embryos, separated the blastomeres(the individual cells) and coated them with artificial zonapellucida (the protective coat surrounding egg cells), and then placed them in various nutrient solutions.

34. Section 3 Human Reproductive Cloning • The outcome was the production of forty-eight new embryos from the original ones. • The cells continued to divide, but development stopped after six days, partly because the embryos were abnormal—the originals were chosen just because they were defective. The work was purely experimental, and it was never intended that the embryos would be implanted.

35. Section 3 Human Reproductive Cloning • Both human cloning and twinning raise ethical issues. • Cloning and twinning raise a concern common to other forms of genetic and reproductive technology: all these techniques are “unnatural”; they represent morally questionable intrusions into ancient processes that should best be left as they are. • In making widespread use of them we are potential creating a world of “Frankensteins” and potentially undermining a long-establishedmoral order.

36. Section 3 Human Reproductive Cloning • But cloning and twinning also open the door to more specific possibilities which raise unique ethical questions: • Twinning could increase the supply of implantable embryos for couples with fertility problems. If a couple’s embryos, produced by in vitro fertilization, can be used to produce several more embryos, these can be used in repeated implantation attempts, thus avoiding the drawbacks of triggering multiple ovulations.

37. Section 3 Human Reproductive Cloning But this is technically a short step from producing a number of genetically identical humans. Combined with our ability to freeze embryos, the following scenarios can be imagined: 1. The production of several identical embryos wouldmake a market in embryos possible. If a child hadalready been born and could be shown to have desirable qualities, the couple who had produced the embryos might sell them at high prices. 2. Parents could have a family in which all their children were genetic copies of one another.

38. Section 3 Human Reproductive Cloning 3. A couple might have a child, while also freezing an embryo twin as a spare. If the child should die, then the genetic twin could be grown from the embryo. 4. If embryo twins were frozen and stored, they could be implanted in gestational mothers years apart. 5. Twins of an individual might be stored so that if the person needed something like a bone-marrow or kidney transplant, the twin could be implanted in a gestational surrogate and allowed to develop.

39. Reading: The Wisdom of RepugnanceLeon R. Kass Kass argues that the repulsion many people feel about the possibility of human cloning springs from a recognition that it violates our nature as embodied, engendered, and engendering beings and the social relations we have because of that nature. First, cloning would distort the cloned person’s sense of individuality and social identity. Second, like IVF and prenatal genetic testing, cloning would transform procreation into manufacture and children into commodities. Third, cloning would encourage parents to regard children as property.

40. Reading: The Wisdom of RepugnanceLeon R. Kass • In contrast to those who see cloning as simply another technique, like artificial insemination and IVF, for helping individuals exercise their “right” to reproduce, Kass regards cloning as a significant slide down the slippery slope toward the “sperm to term” production of genetically designed children. • As a consequence, Kass urges an international legal ban on human cloning.

41. Reading: The Ethics of Human Reproductive CloningCarson Strong • Carson Strong addresses the question of whether, if human cloning were a procedure that didn’t produce birth defects, it would be morally legitimate for some infertile couples to employ cloning to have a genetically related child. • The objections to human reproductive cloning, he claims, are of three kinds:

42. Reading: The Ethics of Human Reproductive CloningCarson Strong • Those that appeal to the interest of the child, • Those based on the consequences to society, and • those arising from teleological views. Strong examines objections to all three types and argues that each objection involves problems so serious as to keep it from being sufficiently compelling. He concludes that human reproductive cloning could be ethically justifiable in at least some instances.

43. Section 4: Surrogate Pregnancy • A gestational surrogate is a “host mother,” a woman who is artificially inseminated (implanted) with an embryo produced from the egg of another woman (egg donor) through the process of in vitro fertilization (fertilization outside a woman’s body). • The surrogate mother, not the egg donor herself, carries the baby to term.

44. Section 4: Surrogate Pregnancy • Surrogate mothers are sought for a variety of reasons. For example, a wife with normal ovaries may not be able to conceive because of the medical condition of her uterus. • The wife and husband may decide to create an embryo through IVF and then have it implanted in another woman who would serve as surrogate. • The resulting child would be genetically related to the wife and husband and not to the surrogate mother.

45. Section 4: Surrogate Pregnancy • Surrogate pregnancies typically occur as part of an explicit legal contract which involves paying the surrogate. But because it is illegal to buy a child or to pay a woman for conceiving and bearing a child, payment is justified only as a compensation for inconvenience or loss of time. • However, critics have charged that these legal maneuverings are merely disguised forms of “baby selling” or prostitution (since, like a prostitute the surrogate is “renting” her body for a fee).

46. Section 4: Surrogate Pregnancy • But the most serious objection to surrogate motherhood is that it is exploitative. Surrogates are likely to be women with low-paying jobs or no jobs at all and are therefore desperate for money. • Finally, it is sometimes argued that the legal quarrels over legal custody of children resulting from surrogacy can have an unacceptably negativeimpact on the childrens’ well-being.

47. Reading: Surrogate Motherhood as Prenatal AdoptionBonnie Steinbock • Bonnie Steinbock reviews the Baby M case (discussed on page 352) and maintains that the court decision was inconsistent in considering the best interest of the child. • The aim of legislation, she claims, should be to minimize potential harms and prevent cases like that of Baby M from happening again. This can be so only if surrogacy is not intrinsically wrong.

48. Reading: Surrogate Motherhood as Prenatal AdoptionBonnie Steinbock • This leads Steinbock to examine three lines of argument and attempt to show that neither paternalism of the sort outlined by Gerald Dworkin (see Chapter 2) nor such consideration as threats of exploitation, loss of dignity, or harm to the child are adequate to show that surrogacy is inherently objectionable. • In Steinbock’s view, regulating surrogacy—and protecting liberty—is preferable to prohibiting it.

49. Reading: Is Women’s Labor a Commodity?Elizabeth S. Anderson • The author argues that commercial surrogacy should not be allowed. The practice of paying women to be surrogate mothers involves a “commodification” of both children and women. • It treats women and their children as things to be used, instead of as persons deserving respect. Hence, surrogacy contracts should be unenforceable, and those who arrange them should be subject to criminal penalties.

50. Reading: Is Women’s Labor a Commodity?Elizabeth S. Anderson • Anderson holds that the introduction of market values and norms into a situation previously based on respect, consideration, and unconditional love has the effect of harming children and degrading and exploiting women. • The values of the market contribute to a tendency to view children as property. When this happens, they are no longer valued unconditionally (as is the case with parental love), but are valued only because they possess characteristics with a market value.