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Ethical issues inassisted reproductive

technologiesEffy Vayena

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Assisted Reproductive Technologies (ART)

All treatments or procedures that include thein vitro handling of human oocytes andhuman sperm or embryos for the purpose of

establishing a pregnancy

(in vitro fertilization and transcervical embryo transfer, gamete

intrafallopian transfer, zygote intrafallopian transfer, tubalembryo transfer, gamete and embryo cryopreservation, oocyteand embryo donation, gestational surrogacy)

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First Successful IVF: Birth of Louise Brow n in 1978

Louise Brown celebrated her

25th birthday in July 2003

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Since 1978 over one mill ion children bornworldwide

Event launching the WorldEvent launching the World

Infertility Month at the UnitedInfertility Month at the UnitedNations in New YorkNations in New York

in June 2002in June 2002

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Rapid developments in the field of ART

Moral panic about the changes that IVF brought about

Continuous ethical dilemmas

Legislation

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Rapid Developments

Better protocols for ovulation induction

Success rates

ICSI

PGD Cloning techniques (animal cloning and claims for

human cloning)

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Moral panic

No society has been neutral aboutreproduction

social values

morals

fears

Separation of sex from reproductionReproduction with the involvement of a third partyGender issuesPronatalist attitudes

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Ethical concerns

Ideology or religion

Status of the embryo

Sanctity of the familysgenetic lineage

Utilitarian principles

Best for society

Best interest of the child

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Ethical concerns

safety

autonomybeneficence

justice

Status of embryo

risks-benefits

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Infertile individual

Infertile coupleChild

Physician

Society

autonomy

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Ethical concerns/ autonomy

Autonomy

Patients autonomy (respect for autonomy)

Reproductive freedom Decision based on accurate information

Issue of success rates

Woman requests implantation of seven embryos

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Ethical issues/ autonomy

Eligibility

all infertile couples

only married couples single women w ithout partners

gay couples

lesbian couples

menopausal women

HIV-positive women or couples

58-year-old couple seeks ART

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.

A gay couple, Janice and Lisa, had been in a stable relationship forover five years and decided to have a family. One would becomepregnant using donor sperm, and they w ould both raise the child in aloving environment. The women had top private health cover, socould easily afford the procedure, both w ere professional women and

could also easily afford the costs associated w ith raising a child,how ever, neither disclosed their sexual preference when theyentered the programme. (There was formal opportunity to do so inthe various application forms)

Upon discovering the nature of their relationship the Director of theclinic, refused to allow them to continue in the programme on thebasis that the legislation allows for couples where conception cannotoccur naturally. He stated that a preliminary medical examination

revealed both women could in fact conceive naturally, their problemin not achieving conception w as due to a sexual preference, not abiological problem, thus they did not actually need the in-vitroprocedure to have a baby, moreover given that the couple were gay,they did not qualify for access to the programme.

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Ethical concerns/ donation

Gamete donor

Sperm

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Ethical issues/donation

EGG DONOR NEEDED

Couple seeks egg donor w ith 1420 SAT or 33 ACT, 18-28 yrsold, 54-5 10, attractive, athletic and healthy. Grandparents

European and at least one Jewish.Compensation is $25,000.Email photos and scores to Nancykp9@aol.com

Commercialization

Ethical arguments against (exploitation,potentiality, dignity, risk for distinctions in genetic

pedigree) Ethical arguments for (justice, pay for a

service, reward, reproductive tourism)

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Ethical issues/ donation

alternative sources of donor eggs

Eggs and ovaries from aborted female fetusesRepugnanceRespect of dignityBest interest of the child

Donation of eggs and ovaries after a womans deathExistence of consentBest interest of the child

Egg sharing

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Ethical issues/ donation

Donor anonymity

(i) the right of autonomy and privacy of the parents;

(i i) the right of privacy of the donor;(ii i) the right of the child to know his/ her origins.

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Ethical issues/ PGD

Pre-implantation genetic diagnosis (PGD)

screening of cells from preimplantation embryos for the

detection of genetic and or chromosomal disordersbefore embryo transfer

Status of the embryoDiscriminationDesigner babies

Sex selectionDestruction of unwanted embryos

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Ethical issues/ PGD

Sarah is 30 years old. Previous genetic testing shows that sheis a carrier for cystic fibrosis (CF). Her partner is a carrieras well. Despite the fact that she is not infertile, she seeks

IVF treatment at an assisted reproduction clinic at an NHSTrust Hospital in order that any resulting embryos can bescreened using pre-implantation genetic diagnosis (PGD)and only embryos without the CF gene will be implanted.

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Ethical issues/risks-benefits

The welfare of the child

Medical risks

Family environment

Social environment

Who is making the decisions for the welfare ofthe child?

Parents

Medical personnel Society and the law

Is it in ones best interest to be born?

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Ethical issues/ risks-benefits

High incidence of mult iple pregnancies

4.6

22.720.922.824.7 27.3

4.14.3

3.4

4.2

0%

10%

20%

30%

40%

1989 1991 1993 1995 1998

Multiplegestationrat

Twin Triplet or more

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Ethical issue/ multiple pregnancies

Two reasons driving the increaseNeed for better success ratesPatients choice/ pressure (lack of accurate information)

International attempts toreduce multiple pregnancies

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Ethical issues/ ART in developing countries

Magnitude of infertil ity

Access to quality ART clinics/ justice- safety

Issue of resource allocation/ justice

Countries reporting to ICMART in 1998

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Countries reporting to ICMART in 1998

g Developed

g Developing

g Economiesin transition

Countries reporting to ICMART in 1998 and countries

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where ART is available but no data reports

Developed

Developing

Economiesin transition

ART availablebut not reporting

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overpopulation

limited resources and burdenof disease

poorly trained practitionersoffering demanding services

cultural and religious values

Main arguments

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0

1000

2000

3000

4000

5000

6000

China

Jordan

Lebanon

Malaysia

Pakistan

Sau

diArabia

Thailand

p.c. healthp.c. health

expenditureexpenditure

cost per IVFcost per IVF

cyclecycle

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The Slippery Slope