Society and artificial reproduction

Should the state assist with conception where it would not approve an adoption?
Margaret Somerville | Feb 17 2009 | comment  



Nadya SulemanTwo cases -- one in California, the other in Calgary -- involving the use of new reproductive technologies have been the focus of intense media attention recently.

Nadya Suleman, a 33-year-old Californian single mother, just gave birth to octuplets. She already had six children aged seven years or under and says all 14 children were conceived through in-vitro fertilization with sperm donated by a friend. The octuplets were delivered prematurely by Caesarian section and will likely spend several weeks in a neo-natal intensive care unit, at a cost of hundreds of thousands of dollars.

Ranjit Hayer, a 60-year-old Calgary married woman, just gave birth to twin boys conceived from donated ova and her husband's sperm. She had been trying for decades, including using reproductive technologies, to have a child, but until now had been unsuccessful. Canadian physicians refused her access to IVF because of her age, so she underwent this procedure in India and returned to Canada for care during her pregnancy and giving birth to premature twin boys. Both required special care -- one, neonatal intensive care -- and serious medical complications ensued for Ms Hayer.

 

Our approach to adoption is a better guide to the ethics of using these technologies ...  because in both cases the resulting families are constructed with state assistance, rather than occurring naturally.

What ethical questions do these situations raise? And what insights or lessons might they provide?

First, we need to distinguish between natural conception and conception where there is reliance on technology. It is one matter, ethically, not to interfere with a person's decisions regarding conceiving a child when that is a purely personal and private decision as it is with natural conception; it's quite another when society provides its resources to facilitate that outcome and the institution of medicine is involved.

With rare exceptions, such as the prohibition of incest or under-age sexual relations, when natural conception unassisted by technology is involved, personal autonomy and personal and family privacy must be given priority. In short, as Pierre Trudeau famously said, "The state has no place in the bedrooms of the nation."

When technology is involved in conceiving a child, we are, however, not in the bedrooms of the nation, but the laboratories, hospitals and clinics of the nation. And the creation of new human life is not an outcome of private love-making, but of actions undertaken by health-care professionals using research and facilities paid for with taxpayers' money. That means the state has ethical obligations, in particular, to ensure the protection and wellbeing of the future children who will result from those activities.

What are society's ethical obligations with respect to reproductive technologies? Despite the extensive work of the Royal Commission on New Reproductive Technologies in the 1980s and 1990s, and the passage of the Assisted Human Reproduction Act by Parliament in 2004, we still don't seem to have reached any working consensus in this regard. We have tended to equate the use of reproductive technologies to natural conception and birth and, more or less, to regard the former through the same ethical lens as natural conception.

Adoption as an ethical model

I suggest that is a mistake; natural conception and conception through reproductive technologies are more different than they are the same. Rather, I propose that our approach to adoption is a better model to guide the ethics of using these technologies, including because in both cases the resulting families are deliberately constructed with state assistance, rather than simply occurring naturally.

Adoption is a long-standing example, in which we have considerable accumulated wisdom, of society fulfilling its obligations to look after those of its members who are unable to look after themselves. The state is also complicit in adoption because it transfers legal parenthood from the biological parent(s) to the adopting parents. That complicity places obligations on the state.

In adoption, the "best interests" of a particular child must always be given priority over the claims, preferences or interests of others. Parliament endorsed this same rule as the first principle of the Assisted Human Reproduction Act: It requires that "the health and well-being of children born through the application of assisted human reproductive technologies be given priority in all decisions respecting their use."

In adoption, assessing the best interests of the child includes examining whether their needs can be fulfilled by potential adoptive parents; whether those potential parents are suitable, including with respect to their age; taking into account the impact of other children in the family on the adopted child and vice versa; whether the adopting parents have adequate financial resources, and so on.

I suggest that the same approach should be taken to decide whether to exclude any particular person from having access to reproductive technologies. At the least, especially when the future child will not be genetically related to one or both parents, as happens when donated gametes are used, the conditions for having access to reproductive technologies should not be any less demanding than those for adoption. It's a further question what other considerations should exclude people not excluded on this basis.

So, if the prerequisites established by the state in order to safeguard the best interests of children mean that Nadya Suleman as a single woman with six children, living with her parents and still studying, could not adopt a child -- let alone eight children -- then she should not be given access to reproductive technologies to have more children.

Likewise, if Ranjit Hayer, as a 60-year-old woman did not meet the state's requirements to adopt, then she should not have access to donated ova and reproductive technologies to have children, and that's quite apart from other reasons, such as risks to the children, for example, of prematurity, the cost to the health-care system, the children's loss of biological identity and connection in being born from donated ova, and so on.

Respect for nature as a guide

Although some people are very negative about using a basic presumption of respect for nature and the natural as a foundation for ethical analysis in relation to reproductive technologies, I believe that used carefully and in conjunction with other ethical analysis, this approach can provide guidance.

Critics inevitably argue that we interfere with nature and the natural all the time (which is true), so, therefore, it is not a valid or useful ethical principle. But respect for nature and the natural does not mean that we cannot interfere with nature and the natural; rather, it means that we must show we are ethically justified in doing so.In the vast majority of cases such justification is patently obvious. But the same is not true for some of the interventions reproductive technologies make possible, which is precisely why this principle is useful in that context. Indeed, much of the conflict around the use of these technologies arises from disagreement as to whether the interferences with nature and the natural that they entail are ethical.

Another contested distinction -- whether in using reproductive technologies we are repairing nature when it fails, or we are using these technologies to do something that is impossible in nature -- can also provide ethical insights.

Repairing nature usually involves less serious ethical issues than doing the impossible. Take Ms. Hayer's situation: infertility resulting from normal menopause is not an illness and is common to all women at a certain age, so using technology to create a post-menopausal pregnancy is doing what is not possible in nature, rather than repairing nature. In comparison, using IVF to overcome blocked fallopian tubes in an otherwise fertile 27-year-old woman is repairing nature.The question of the ethics of doing what is impossible in nature with respect to human reproduction is likely to become much more important and contentious in the future. For example, should young women, as is presently happening, be able to store ovarian tissue to first have their careers and then have babies in their fifties and sixties? Should we prohibit the use of artificial sperm and ova made from adult stem cells? What about creating a baby with more than two genetic parents or making a shared genetic baby between two men or two women? What about a man who wants a uterus transplant?

And wider questions will multiply. Where should we draw the line between protecting personal, private decision-making about reproduction and allowing -- or even requiring -- societal involvement in that decision making? What rules should health care professionals be bound by in using these technologies?

In a relatively short period of time -- just 31 years since the birth of the first IVF baby in 1978 -- reproductive technologies have rapidly become a multi-billion-dollar international industry, with 29 IVF clinics currently operating in Canada, almost all of them on a private, for-profit basis. Do we, as Canadians, want an ever-increasing commercial industry presence in human reproduction? What should our health-care systems pay and not pay for? And so on.

At base here is the question of children's fundamental human rights with respect to their coming into being, their biological parents and other relatives, and the family structure in which they will grow to be adults. We are the first humans ever to have the technological power to affect these rights of children. We have an enormous responsibility to ensure that we "first do no harm", especially to those children who would be directly impacted by reproductive technologies, no matter how much adults might wish to fulfill their own desire for a baby.

Margaret Somerville is director of the Centre for Medicine, Ethics and Law at McGill University.



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