Ethical Dilemmas in Assisted Reproductive Technologies (eBook)

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Joseph G. Schenker, Hebrew University, Hadassah Hospital, Jerusalem, Israel.

Joseph G. Schenker, Hebrew University, Hadassah Hospital, Jerusalem, Israel.

Contents 6
Preface 18
Author index 22
1 The foundations and application of medical ethics 26
1.1 Introduction 26
1.2 Historical background 26
1.3 General ethical theories and principles 27
1.4 Modern medical ethics 33
1.5 Conclusion 38
2 Legislation for assisted reproductive technologies 40
2.1 Introduction 40
2.2 Legislation and regulations 41
2.3 Legislative motivations 43
2.4 Evidence-based legal policy 45
2.5 The focus of legislation 47
2.6 Human rights 50
3 Reproductive rights as an integral part of women’s rights 54
3.1 Introduction 54
3.2 Granting women equal rights: the origin of discrimination 55
3.2.1 Cornerstones of women’s rights 57
3.2.1.1 Dignity, body integrity, and freedom from violence 57
3.2.1.2 Equality and empowerment 59
3.2.1.3 Full, unconditional access to health care services 60
3.2.2 A right to treat infertility 61
4 Right to reproduce 68
4.1 Socioeconomic issues 68
4.2 Religious issues 70
4.3 Legal and historical aspects 70
4.4 Moral aspects 73
4.5 ART-related aspects 74
5 Informed consent for treatment of fertility 78
5.1 Introduction 78
5.2 The right to experience parenthood and its standing 79
5.3 The informed-consent doctrine 80
5.3.1 The doctrine and its nature 80
5.3.2 Application of the doctrine to fertility treatments 80
5.4 Mutual consent of spouses 81
5.4.1 Joint process 81
5.4.2 The good of the child and consideration of parental capability 82
5.5 Validity of the consent 83
5.5.1 Effect of the initial consent 83
5.5.2 Withdrawal of patient consent 84
5.5.3 Physician’s withdrawal of consent 84
5.5.4 Consent after death 85
5.5 Conclusion 85
6 Specific ethical and legal aspects of ART practice in eastern European countries 88
6.1 Introduction 88
6.2 Situation in eastern European countries 88
6.2.1 Number of centers 88
6.2.2 Legal regulation of ART 89
6.2.3 Coverage or reimbursement of ART 90
6.2.4 Marital status in ART 91
6.2.5 The number of transferred embryos in ART 92
6.2.6 Cryopreservation 93
6.2.7 Posthumous ART 95
6.2.8 Gamete donation 96
6.2.9 Anonymity 97
6.2.10 Micromanipulation 98
6.2.11 In vitro maturation of oocytes 99
6.2.12 Welfare of the child 100
6.2.13 Multifetal-pregnancy reduction 101
6.2.14 Preimplantation genetic diagnosis 102
6.2.15 Surrogacy 103
6.2.16 Research on the embryo 104
6.2.18 Gamete intrafallopian transfer 106
6.2.19 The moral status of the embryo 106
6.3 Conclusions 107
7 Sperm donation and sperm-bank management 112
7.1 Introduction 112
7.2 Limiting the number of donor offspring 113
7.2.1 United States 113
7.2.2 United Kingdom 113
7.3 Minimizing the risk of infection and genetic complications from sperm donors 114
7.4 Age requirements for sperm donors 114
7.5 Anonymity versus nonanonymity of sperm donors 115
7.5.1 Anonymous sperm donation 115
7.5.2 Nonanonymous sperm donation 116
7.6 Sperm-donor compensation 117
7.7 Informed consent and counseling 118
7.8 Conclusions 118
8 Oocyte donation: medical and legal perspectives 120
8.1 Introduction: Indications for egg donation 120
8.2 Preparation of donor and recipient 121
8.3 Outcome determining factors 123
8.4 Obstetric and perinatal outcomes 123
8.5 Ethical aspects 124
8.6 Legislation 126
8.6.1 The new Israeli legislation 129
8.7 Summary 132
9 Egg donation: ethical considerations and regulatory context 136
9.1 Introduction 136
9.2 The regulatory context 136
9.3 Donating eggs 137
9.3.1 Informed consent 137
9.3.2 Meeting demand: remuneration and other programs 138
9.3.2.1 Financial compensation 138
9.3.2.2 Egg-sharing programs 139
9.3.3 Other obligations 140
9.4 Use of donated eggs 140
9.4.1 Informed consent 140
9.4.2 Nontraditional patients and access to donated eggs 140
9.4.3 Age 141
9.5 Donor identity and disclosure 141
9.6 Conclusions 143
10 Medical, ethical, and legal aspects of fetal reduction 146
10.1 History 146
10.2 Ethical issues 148
10.2.1 Moral compromise 152
10.3 Legal issues 153
10.3.1 Recommendations 153
10.4 Summary 154
10.5 Acknowledgments 154
11 Fertility treatments in human immunodeficiency virus (HIV) infected patients 156
11.1 Introduction 156
11.2 HIV and the male genital tract 157
11.3 HIV and the female genital tract 158
11.4 Assisted reproductive technologies in HIV-positive patients 158
11.5 Semen processing 159
11.6 Viral testing of spermatozoa 160
11.7 Success rates 160
11.8 Summary 160
12 Pregnancies in perimenopause and beyond 164
12.1 Medical aspects and considerations 164
12.1.1 Fertility fecundity and abortions 164
12.1.2 Pregnancy-associated physiological changes 165
12.1.3 Obstetrical and intrapartum complications 165
12.1.4 Maternal mortality 166
12.1.5 Neonatal outcome 166
12.2 Oocyte-donation programs 166
12.3 Ethical aspects 167
12.3.1 The issue of choice 167
12.3.2 The welfare of the child 168
12.4 Coping with the medical risks 168
12.5 Legislation, regulation, and religion aspects 169
12.6 Summary 170
13 Legal control of surrogacy – international perspectives 174
13.1 Introduction 174
13.2 Surrogacy – definition 174
13.3 Surrogacy – history 174
13.4 Legal control of surrogacy – international perspectives 175
13.4.1 Prohibition of Surrogacy by legislation 175
13.4.2 Counties – surrogacy no prohibited by law 176
13.4.3 Surrogacy in China 177
13.4.4 Non commercial surrogacy 177
13.4.5 Greece Law 177
13.4.6 South Africa 178
13.5 Commercial surrogacy 178
13.5.1 Former Countries of the Soviet Union 178
13.5.2 India 179
13.5.3 Surrogacy in USA 179
13.5.4 Surrogacy in Russia 180
13.6 Russian Public Opinion 183
13.7 Surrogacy in Islamic Countries 183
13.8 Cross-border Surrogacy 184
13.9 Conclusions 186
14 Preimplantation genetic diagnosis in assisted reproduction: medical, ethical, and legal aspects 190
14.1 Introduction 190
14.2 Biopsy methods for preimplantation genetic diagnosis 191
14.2.1 Polar-body biopsy 191
14.2.2 Embryo biopsy 192
14.3 Chromosomal aneuploidies in preimplantation development 192
14.4 Chromosomal rearrangements 194
14.5 Impact of PGD on IVF outcome 195
14.6 Conclusion 197
15 Preimplantation genetic diagnosis of late-onset diseases 200
15.1 Introduction 200
15.2 Embryo selection 202
15.3 Huntington’s disease 203
15.4 Cardiovascular disorders 205
15.5 Alzheimer’s disease 206
15.6 Genetic testing for cancer 206
15.7 Breast cancer 207
15.8 Genetic counseling 210
15.9 Conclusion 210
16 Bioethics of human embryonic stem cells and cloning for stem cells: an Israeli perspective 214
16.1 The scientific and medical aspects 214
16.2 Ethical issues related to human embryo stem cells 215
16.2.1 Pluralism of moral views on the preimplantation embryo 215
16.2.2 Potentiality of human preimplantation embryo 216
16.2.3 Personal status of the embryo 216
16.2.4 Therapeutic aims of human ES cells 217
16.2.5 Pluralism of decisions on human ES cell production and research in various countries 217
16.2.6 A case study: ethical regulations on human ES cell research in Israel 219
16.3 Ethical views on cloning to obtain autologous ES cells 220
16.3.1 Bioethical arguments 220
16.3.2 National and international resolutions 221
16.3.3 Case study: regulations in Israel regarding cloning for ES cells 222
17 The future of human embryonic stem cell research: medical, legal, and ethical perspectives 226
17.1 Introduction: Human embryonic stem cell research 226
17.2 The first possible clinical applications of cells differentiated from hESC 226
17.3 Challenges in clinical treatment using hESC-derived cells 227
17.3.1 Microbial contamination 227
17.3.2 GMP and EU tissues and cells directive 227
17.3.3 Immunogenicity 228
17.3.4 Tumorigenicity 228
17.4 iPS cells versus hESC 229
17.5 Legal and ethical aspects of hESC research 229
17.6 Conclusions 231
18 Preservation of fertility in children with cancer: medical, ethical, and legal aspects 234
18.1 Introduction 234
18.2 Population at risk 235
18.3 Medical and surgical options for fertility preservation 236
18.4 The ethical propriety of fertility-preservation options 237
18.5 Autonomy, justice, and treating pediatric patients 239
18.6 Ethical and legal issues with unused tissue and gametes 239
18.7 Posthumous reproduction 240
18.8 Conclusion 241
19 Fertility preservation for cancer patients: a review of current options and their advantages and disadvantages 244
19.1 Introduction 244
19.2 Cancer and fertility preservation 244
19.3 Current options for fertility preservation 245
19.4 Medical options: GnRH agonists 245
19.5 Surgical options: ovarian transposition and cryopreservation of ovarian cortical tissue 246
19.5.1 Ovarian transposition 246
19.5.2 Cryopreservation of ovarian cortical tissue 247
19.6 ART: in vitro fertilization and in vitro maturation 248
19.6.1 Embryo and oocyte cryopreservation after ovarian stimulation 248
19.6.1.1 Embryo cryopreservation 248
19.6.1.2 Oocyte cryopreservation 249
19.6.2 Embryo and oocyte cryopreservation without prior ovarian Stimulation 250
19.6.3 IVM embryo cryopreservation 251
19.6.4 IVM-oocyte vitrification 251
19.6.5 Fertility preservation: the McGill experience 252
19.7 Conclusion 252
20 Sexual orientation and use of assisted reproductive technology: social and psychological issues 258
20.1 Introduction 258
20.2 A note about terminology 258
20.3 Routes to parenthood among nonheterosexual adults 259
20.4 Legal issues surrounding sexual orientation and family formation 259
20.5 Sexual orientation and incidence of parenthood 260
20.6 Sexual orientation and plans for parenthood 260
20.7 Studies of sexual orientation and plans for parenthood 261
20.8 Outcomes for children of lesbians and gay men 262
20.9 Relationships with peers 262
20.10 Child behavior problems 263
20.11 Gender development 263
20.12 Conclusions and future directions 264
20.13 Assisted reproduction among nonheterosexual adults 264
20.14 Barriers to ART use by nonheterosexual adults 264
20.15 Donor-insemination decisions 266
20.16 Recommendations for clinical practice 267
20.17 Conclusion 268
21 Access to fertility treatment by lesbian couples 270
21.1 Introduction 270
21.2 Legal changes 271
21.3 Assisted reproduction 274
21.4 Being a lesbian and a mother 275
21.5 Donor anonymity 275
21.6 Ethical assessment 277
21.7 A Child with two mothers 279
22 ART practice and tourism 282
22.1 Introduction 282
22.2 Background and methods 283
22.3 Major findings 284
22.3.1 The United Arab Emirates 286
22.3.1.1 Reproductive travel to the UAE 286
22.3.1.2 Reproductive travel from the UAE 287
22.3.1.3 Reproductive travel to and from the UAE 288
22.3.2 The East Coast of the United States 288
22.4 Conclusion 290
23 A savior child conceived by PGD/HLA: medical and ethical aspects 294
23.1 Introduction 294
23.2 Medical indications and social acceptance of PGD 294
23.2.1 Chromosomal abnormalities 294
23.2.2 Monogenic diseases 295
23.2.3 Adult-onset diseases and cancer-predisposing genes 295
23.2.4 Creating a “savior child” 296
23.3 Other possible applications of PGD: savior embryos, gender selection, and designer babies 297
23.3.1 Savior embryos 297
23.3.2 Gender selection 298
23.3.3 Designer babies 298
23.4 Legislation and professional guidelines for the uses of PGD/HLA 299
23.5 Ethical considerations 299
23.5.1 Embryo wastage 300
23.5.2 Moral status of the human embryo 300
23.5.3 Harm of embryo biopsy 302
23.5.4 The condition of absolute medical necessity 302
23.5.5 PGD SC and family ethics 304
23.5.6 Well-being of the savior child 306
23.5.7 PGD, parental interests and public access 308
24 Posthumous reproduction: ethical and legal perspectives 314
24.1 Introduction 314
24.2 The source 315
24.2.1 What counts as consent? 315
24.2.2 Coercion 316
24.2.3 Minors as sources 317
24.3 Requesters of retrieval 318
24.4 Reproductive partners 319
24.5 Children 320
24.6 Summary 320
25 Human reproductive cloning: ethical perspectives 322
25.1 Introduction 322
25.2 The potential value of HRC 322
25.3 Ethical concerns with HRC 326
25.4 HRC and the value of our unique genetic make-up 331
25.5 Conclusion 332
26 ART practice – religious views 334
26.1 Introduction 334
26.2 The Jewish law 335
26.2.1 Torah 335
26.2.2 The Mishnah 336
26.2.3 The Talmud 336
26.2.4 Post-Talmudic codes 336
26.2.5 Responsa 336
26.2.6 Orthodox Judaism 337
26.2.7 Reform Judaism 337
26.2.8 Conservative 338
26.3 Christian denominations 339
26.3.1 Roman Catholic Church 339
26.3.2 Anglican Church 340
26.3.3 The Protestant Church 341
26.3.4 Eastern Orthodox Church 341
26.4 Hinduism 342
26.5 Buddhism 343
27 A Catholic ethical perspective on human reproductive technology 346
27.1 Catholic position on respect for the human embryo 346
27.1.1 Biblical perspective 346
27.1.2 Christian tradition 346
27.1.3 Embryo defined 347
27.1.4 Catholic Christian teaching 347
27.1.5 A person from conception 349
27.1.6 Ethics and destructive research on human embryos 349
27.1.7 Morality and personalized natural law 350
27.1.8 Secular ethics and the human embryo 351
27.1.9 Challenge to find ethical alternatives 352
27.2 Catholic ethics, marriage, and reproductive technology 352
27.2.1 Catholic Christian position on children of the marriage union 352
27.2.2 Assisted insemination 353
27.2.3 Rights of children and natural parents 354
27.2.4 Donor gametes 354
27.2.5 Surrogacy 354
27.2.6 Access to ART by single women and lesbians 355
27.2.7 Human reproductive cloning 355
27.3 Conclusion 355
28 Islamic laws and reproduction 358
28.1 Islamic laws 358
28.2 Reproduction in Islam 358
28.3 ART and Islam 359
28.4 Islam and various ART practices 360
28.5 Surrogacy 360
28.6 Multifetal pregnancy reduction 360
28.7 Pregnancy in postmenopause 360
28.8 Sex selection 361
28.9 Cryopreservation 362
28.10 Embryo implantation following husband’s death 362
28.11 Embryo research 363
28.12 Gene therapy 363
28.13 Cloning 364
28.14 ART practices in different Muslim countries 364
29 Jewish law (halakha) and reproduction 368
29.1 Introduction 368
29.2 Homosexuality 369
29.3 Lesbianism 369
29.4 Evaluation of the infertile couple 370
29.5 The laws of niddah 370
29.6 Infertility treatment 371
29.7 The beginning of human life 373
29.8 Artificial insemination by husband 375
29.9 Artificial insemination by donor 375
29.10 Oocyte donation 376
29.11 Surrogacy 377
29.11.1 Legalizing surrogacy in Israel 378
29.11.2 The state-appointed permission committee 378
29.11.2.1 Guidelines set by the committee for surrogacy 378
29.11.2.2 Expenses 379
29.11.2.3 Legal status of the newborn 379
29.11.2.4 Surrogate mother’s withdrawal from the agreement 379
29.11.2.5 Legal rights of the surrogate mother 380
29.11.2.6 Enforcement of the law 380
29.11.2.7 Right to privacy 380
29.11.2.8 Illegal financing 380
29.11.2.9 Legal adoption 380
29.12 Fetal reduction 381
29.13 Gender preselection 382
29.14 Cryopreservation 382
29.15 Posthumous reproduction 383
29.16 Cloning 384
29.17 Preembryo research 385
30 Commercialized assisted reproduction 388
30.1 Position of reproductive treatment in the economy 388
30.2 Commercialization of assisted reproduction 388
30.3 Divergent national policies toward reproductive treatment 388
30.4 International economic integration and assisted reproduction 389
30.5 Absence of effective restrictions on reproductive tourism 390
30.6 Natural barriers to reproductive tourism 390
30.7 Intellectual property and assisted reproduction 391
30.8 Doing business in the reproductive industry 391
30.9 Assisted reproduction in united Europe 392
30.9.1 Case study: German patients in Czech centers 393
31 The intersection between economic and ethical aspects of ART 396
31.1 Introduction 396
31.2 A framework for economic and ethical aspects of ART 397
31.3 Distributive justice and funding of ART 398
31.3.1 International differences in funding 398
31.3.2 Provision of ART in developing countries 401
31.3.3 Morally challenging funding decisions 402
31.4 The cost of ART treatment 402
31.4.1 Treatment costs 402
31.4.2 The costs of multiple births 403
31.4.3 Valuing ART treatment from an economic perspective 405
31.5 The affordability of ART treatment and its implications 406
31.5.1 Affordability and utilization 406
31.5.2 Affordability and clinical practice 409
31.5.2.1 It makes economic as well as clinical sense to reduce multiple-births 410
31.6 Conclusion 411