Ethical Issues in Reproductive Technologies

Ethical Issues in Reproductive Technologies Lawrence M. Hinman University of San Diego hinman@acusd.edu 3/28/2008 ©Lawrence M. Hinman 1 Introduction  In the last two decades, we have seen rapid increases in medical technologies designed to assist in reproduction. 3/28/2008 ©Lawrence M. Hinman 2 Types of Technologies – Assisted Reproductive Technologies (ART) – Artificial Insemination (AI) – In Vitro Fertilization (IVF) – Gamete Intra Fallopian Transfer (GIFT) – Zygote Intrafallopian Transfer (ZIFT) – Intracytoplasmic Sperm Injection (ICSI) – Assisted Hatching - Embryo Micromanipulation Source: http://www.fertilitext.org/assttech.htm 3/28/2008 ©Lawrence M. Hinman 3 Assisted Reproductive Technologies (ART) These specialized infertility treatments are designed to increase the number of eggs and/or sperm, or bring them closer together, resulting in improved probability of conception not otherwise possible. Collectively, these medical procedures are called assisted reproductive technologies, or ART. 3/28/2008 ©Lawrence M. Hinman 4 Artificial Insemination (AI) Artificial insemination or AI is often the best choice of treatment for couples that are infertile due to sperm disorders. AI involves injecting sperm through a narrow catheter into the wife's reproductive tract. For most couples, artificial insemination is performed with the husband's sperm. When a man's ejaculate contains few or no live sperm, the couple may decide to undergo AI with sperm from a donor with the characteristics they desire. 3/28/2008 ©Lawrence M. Hinman 5 In Vitro Fertilization (IVF) IVF is the name for in vitro fertilization, a procedure that involves retrieving eggs and sperm from the bodies of the male and female partners and placing them together in a laboratory dish to enhance fertilization. Fertilized eggs are then transferred several days later into the female partner's uterus where implantation and embryo development will hopefully occur as in a normal pregnancy. 3/28/2008 ©Lawrence M. Hinman 6 Gamete Intra Fallopian Transfer (GIFT) – The main difference between IVF and GIFT is that with GIFT fertilization occurs naturally within the female partner's body instead of in the laboratory as with IVF. GIFT is a procedure that involves ovarian stimulation, egg retrieval, and placing a mixture of the sperm and eggs directly into the woman's fallopian tubes to foster fertilization inside the female's body. 3/28/2008 ©Lawrence M. Hinman 7 Zygote Intrafallopian Transfer (ZIFT) • Like IVF, the actual fertilization of the eggs is observed and confirmed in the laboratory. The location of where fertilization takes place, and the ability to confirm actual fertilization, are the main differences between ZIFT and gamete intrafallopian transfer, or GIFT. With GIFT, the actual fertilization cannot be observed because the eggs and sperm are united for fertilization inside the woman's fallopian tube. The advantage of ZIFT over GIFT is that ZIFT uses zygotes, not an egg and sperm mixture. ©Lawrence M. Hinman 3/28/2008 8 Intracytoplasmic Sperm Injection (ICSI) – ICSI, is the newest form of sperm micromanipulation procedure performed in the laboratory. ICSI involves the insertion of a single sperm directly into the cytoplasm of a mature egg, or oocyte, using a microinjection pipette, or thin glass needle. ICSI bypasses both the need to have the sperm swim through the reproductive tract to reach the egg and the need to have the sperm penetrate the egg. ©Lawrence M. Hinman 3/28/2008 9 Assisted Hatching Embryo Micromanipulation Assisted hatching is a form of embryo micromanipulation that involves the creation of an opening in the outer covering of the embryo. This outer covering is known as the zona pellucida, of the embryo. This procedure is used to help the normal, growing embryo to emerge from the covering in order to properly implant in the uterus. 3/28/2008 ©Lawrence M. Hinman 10 Moral Issues     What is the moral status of the egg, sperm, and the fertilized egg? What are the individual moral constraints on trying for reproduction “at any cost”? Dehumanizing aspects of procedures Social implications of widespread use ©Lawrence M. Hinman 11 3/28/2008 What is the moral status of the egg, sperm, and the fertilized egg?   Moral status before sperm and egg come together Moral status after sperm and egg come together but before implantation in the uterine wall – Including frozen fertilized eggs  Moral status after implantation ©Lawrence M. Hinman 12 3/28/2008 Left-over Embryos Typically, during fertility treatments, women may store fertilized eggs, embryos, as part of their treatment. – Kept frozen for unanticipated catastrophe – A kind of immortality – Many major fertility centers have thousands of these--10,000 per year nationally – No federal agency oversees this – Sometimes embryos are donated to infertile couples, but legal issues about parental rights persist. 3/28/2008 ©Lawrence M. Hinman 13 Difficult Cases, 1  Dr. Griffo, at Cornell, has a different problem. He stored embryos for a married woman who subsequently died. Before she died, she said she wanted her embryos destroyed, and her husband agreed, Griffo said. But now, he said, "her husband has changed his mind and says he wants someone to carry the embryos" so he can have his dead wife's babies. ©Lawrence M. Hinman 14 3/28/2008 Difficult Cases, 2 Julie Garber of Anaheim, Calif., who, in 1994, was 26, single and dying from leukemia. She knew her only chance of surviving was to have a bone marrow transplant. Realizing that the treatment would leave her sterile, she decided to store some embryos beforehand. She had one month before the transplant to accomplish this, said her mother, Jean Garber. Ms. Garber and her father, Dr. Howard Garber, a retired optometrist, selected a sperm donor from a sperm bank to fertilize her eggs. She ended up with 12 embryos, which are stored in Anderson's tanks, but she died last December. Her parents are now deciding between two potential surrogates who have agreed to carry the embryos -- their grandchildren -- to term. "This is a love situation," Jean Garber said. The embryos, she added, "are so precious to me." They are a bit of her daughter, she said, "my friend and my business partner and my confidante. I miss her so much." 3/28/2008 ©Lawrence M. Hinman 15 Difficult Cases, 3 A more typical situation, Dr. Sauer said, is that of a couple in their early 30s who had in vitro fertilization and completed their family. Now they have 10 embryos frozen at ColumbiaPresbyterian, and they have not replied to letters asking them whether they want to keep the embryos or have them discarded. Sauer understands. Infertility is a devastating disorder that wreaks havoc on people's lives. The young couple "have a family now," Sauer said. "They don't want to be reminded of that period of their lives." So their embryos remain, frozen in perpetuity. 3/28/2008 ©Lawrence M. Hinman 16 What are the individual moral constraints on trying for reproduction “at any cost”?       Sex selection Genetic screening for so-called “defects” Selective abortion with multiple fetuses Pregnancies and older women Surrogate motherhood Cloning ©Lawrence M. Hinman 17 3/28/2008 Dehumanizing aspects of procedures    Greater freedom of choice Much less natural process Conception as a medical event vs. an act of love 3/28/2008 ©Lawrence M. Hinman 18 Social implications of widespread use  Vast demographic changes – Shift in male/female ratio – Possible decline of two parent family – Possible homogeneity in society 3/28/2008 ©Lawrence M. Hinman 19 Surrogacy  Surrogacy occurs when I woman agrees to carry to term the fetus for another person. – That fetus may be from the egg and sperm of the couple who want to raise the child or it may b donor eggs or donor sperm. 3/28/2008 ©Lawrence M. Hinman 20 Surrogacy: The Possibilities  Intentional mother the woman who wants to have the child   Intentional father the man who wants to have the child Genetic mother the woman who supplies the egg for the embryo embryo  Genetic father the man who supplies the sperm for the  Gestational mother the woman who carries the embryo to term and gives birth to it  Nurturing mother the woman who raises and nurtures the child from infancy as her own child from infancy as his own  Nurturing father the man who raises and nurtures the nurtures the ©Lawrence M. from infancy as child Hinman 21 3/28/2008 his own On-Line Sources  Bibliography of Bioethics Sources on Reproductive Technologies: – http://www.ncgr.org/gpi/grn/edures/elsi.tc6.html – http://ethics.acusd.edu/reproductive_technologies.html  Information on Reproductive Technologies – http://www.fertilitext.org/assttech.htm 3/28/2008 ©Lawrence M. Hinman 22