As reproductive technologies become increasingly advanced, so concerns of misuse grow. Professor M. Sara Rosenthal, founding Director of the University of Kentucky Program for Bioethics, offers her insight into some of the key issues. Rosenthal received her Ph.D. from the University of Toronto Joint Centre for Bioethics, a WHO-affiliated bioethics center. She currently directs U.K.’s clinical and research ethics consultation services, and chairs the Hospital Ethics Committee.
What are some of the ethical issues surrounding reproductive technologies that arise for a doctor?
MSR: The obvious issue is appropriate candidacy: who is a candidate for reproductive technologies, and are there limits to patient autonomy? When should a fertility specialist say: “No, I will not do that”? The Nadya Suleman case (“Octomom”) case was an egregious (yet not so uncommon) situation in which the physician acceded to unsound patient requests for repeated IVF, and in Suleman’s last pregnancy, a transfer of twelve embryos. The physician was stripped of his license by the California Medical Board. The case was a clarion call for stricter guidelines and oversight regarding reproductive technologies in the U.S.; such guidelines have been in place in other countries for years.
Questions abound surrounding age limits. Do we want to make women in their 50s and 60s pregnant, creating situations where pregnancy is high-risk and where children may be orphaned at young ages? There are cases of women as old as 65 who are made pregnant. Ethicists (including myself) who were part of the national dialogue on Suleman have recommended that physicians need to consider psychosocial fitness for patient candidacy.
Gamete donation is another issue; many young women are enticed into selling their gametes for large sums of money. Some ethicists have made the argument that women ought to be paid handsomely for egg donation and surrogacy, given that they are submitting themselves to risks. But such large sums of money create barriers for voluntary consent, and may induce women into decisions they would not otherwise make.
Other issues have emerged over sperm donation, and whether there ought to be limits. We are seeing sperm donors who have created as many as 75-100 offspring — something far outside of what nature intended. However, many of these situations occur without the participation of a healthcare provider, as many healthy women will self-inseminate.
As a bioethicist, at what point do you think a physician should draw a line between medical ethics and personal/religious values and beliefs?
MSR: Autonomous patients have both a moral and constitutional right to make their own decisions about their bodies. Healthcare providers should not impose their own beliefs onto their patients, and must respect there is wide moral and religious diversity. At the same time, healthcare practitioners are not obligated to provide care that violates ethical standards, or would violate the ethical Principle of Beneficence (the obligation to offer care that maximizes clinical benefits and minimizes clinical risks). In reproductive medicine, it is critical for healthcare providers to understand when the embryo or fetus is a patient. There is a role for conscientious objection, but it should not be abused to deny patients procedures or FDA-approved medications that are well within the standards of care, and the patient’s constitutional and legal rights.
The British government recently expressed its support for three-person IVF, which seems to raise ethical questions about parenthood. Can you talk a little about some of the issues you foresee, and about possible solutions?
MSR: The ethical basis for three-person IVF surrounds the elimination of mitochondrial diseases. The nuclear DNA of the parents is retained (this determines all of the child’s characteristics), and only the defective mitochondrial DNA from the mother is replaced with a donor’s healthy mitochondrial DNA. So the child will be genetically related to the parents. This procedure falls within the same category as preimplantation genetic diagnosis. It is essentially about “designer babies” and less about three parents, but the procedure is experimental and indeed raises ethical, legal, and social implications. As with most of the issues in reproductive technologies, the science is ahead of the ethics.
By Fiona Young-Brown