Transcript IVF and Surrogacy - University of Toronto

IVF and Surrogacy
PHL281Y Bioethics
Summer 2005 University of Toronto
Prof. Kirstin Borgerson
Course Website: www.chass.utoronto.ca/~kirstin
Overview
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…Genetic testing (Purdy)…
IVF
– Definitions/distinctions
– Singer (for)
– Sherwin (against)
Selling the body & surrogacy
– Definitions/distinctions
– Baby M Case
– Murray (~against)
– Steinbock (~for)
Purdy: Genetic Testing
and Reproduction
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Huntington's Disease (HD): “a devastating, hereditary,
degenerative brain disorder for which there is, at present, no
effective treatment or cure. HD slowly diminishes the affected
individual's ability to walk, think, talk and reason. Eventually, the
person with HD becomes totally dependent upon others for his or her
care. Huntington's Disease profoundly affects the lives of entire
families -- emotionally, socially and economically…
Early symptoms: depression, mood swings, forgetfulness,
clumsiness, involuntary twitching and lack of coordination
Later symptoms: concentration and short-term memory diminish and
involuntary movements of the head, trunk and limbs increase.
Walking, speaking and swallowing abilities deteriorate. Eventually the
person is unable to care for him or herself. Death follows from
complications such as choking, infection or heart failure”
Huntington’s Disease
“HD typically begins in mid-life, between the ages of 30 and 45,
though onset may occur as early as the age of 2. Children who
develop the juvenile form of the disease rarely live to adulthood…
HD affects males and females equally and crosses all ethnic and
racial boundaries. Each child of a person with HD has a 50/50 chance
of inheriting the fatal gene. Everyone who carries the gene will
develop the disease. In 1993, the HD gene was isolated and a direct
genetic test developed which can accurately determine whether a
person carries the HD gene. The test cannot predict when symptoms
will begin. However, in the absence of a cure, some individuals "at
risk" elect not to take the test”
(Huntington’s Disease Society of America (www.hdsa.org))
Reproductive Threshold
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Moral Minimalism – “it is morally permissible to conceive
individuals so long as we do not expect them to be so
miserable that they wish they were dead”
– Puts no demands on us
– Not many people would want to live in a world where this was
the prevailing standard
– Doesn’t pay much attention to human well-being
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Minimally Satisfying Lives – “we ought to try to provide every
child with something like a minimally satisfying life” (523)
– Minimally satisfying = many elements. Purdy focuses on ‘health
normal for that culture’ (for this argument)
– Huntington’s disease does not meet this standard (in virtually all
societies) according to Purdy
Purdy’s Argument
1.
We ought to provide every person with a minimally satisfying life
[from Utilitarian or Contractarian moral theory]
2.
People with HD* are unlikely to live a minimally satisfying life
[empirical claim]
3.
People currently living with HD are at high risk of passing on HD
to their children
4.
We ought to prohibit people currently living with HD from having
genetically related children
5.
People currently living with HD are morally obligated to prevent
the conception of genetically related children (or test for and abort
fetuses with HD)
*Huntington’s disease is used here but may be replace by any
other genetic disease that we know to be the cause of a life
that is not minimally satisfying as defined by Purdy
Analysis
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Objection: Right to reproduce
– What reasons do we have for this right?
– Love, companionship, shaping a new generation?
 Reply: adoption, AI, egg donation, IVF, cloning
– Immortality, mini-me?
 Reply: narcissistic? false?
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Objection: Right not to know
– Defensible only when ignorance does not put others at serious
risk
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Implications?
Genetic Engineering
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Treatment
Enhancement
Reproductive Technologies
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Natural human reproduction = sexual intercourse, tubal
fertilization, implantation in the uterus, and subsequent in
utero gestation
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Reproductive technologies replace one or more of these steps:
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Artificial Insemination – often used to overcome male infertility (with
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In Vitro Fertilization (IVF)– “fertilization in a glass”. Sperm and egg
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Future possibility of ectogenesis
would replace final two steps
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original male’s sperm or with donor’s sperm). Also sometimes used as a form
of positive eugenics. Can be used in conjunction with surrogacy to overcome
female infertility. Replaces first step.
united in a petri dish, grown to eight-cell stage. Combined with embryo
transfer. Replaces first two steps.
(artificial gestation) – artificial womb
Note: development of PGD (preimplantation genetic diagnosis) allows couples
at risk of transmitting genetic diseases who make use of IVF to test and
discard affected embryos
In Vitro Fertilization (IVF)
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Reproductive technologies such as IVF
bring the embryo outside of the human
body
‘Test tube babies’
Used most commonly by people with
certain types of infertility (ex/ blocked
fallopian tubes), and by couples who
don’t want to pass on a genetic disease
(ex/ MS, Huntington’s)
Arguments Against IVF (with
objections - Singer)
1.
IVF is unnatural
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2.
Modern medicine as a whole? (Ex/ prescription drugs, surgery,
chemotherapy)
Using our intellect to overcome adversity
IVF is risky for the offspring
–
Rate of abnormality with IVF is similar to that with natural
reproduction (slightly higher but within reasonable limits)
…
3.
IVF separates the procreative and the conjugal
aspects of marriage and so damages the marital
relationship
–
4.
IVF can actually strengthen marriage, as infertile couples will
then be able to have a much wanted child
IVF is illicit because it involves masturbation
–
Even if a prohibition on masturbation for sexual pleasure could
be defended, in this case masturbation is being used to
strengthen the marriage bond and procreate & this would
seem to warrant separate analysis
…
5.
6.
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Adoption is a better solution to the problem of
childlessness
IVF is an expensive luxury and the resources would be
better spent elsewhere
These objections to IVF rely on the principle that we ought to find
loving families for unwanted or orphaned children before creating
additional children
Recall: Singer is the philosopher who made the argument about
our moral obligations to those in absolute poverty (from the first
lecture).
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“We cannot demand more of infertile couples than we are
ready to demand of ourselves. If fertile couples are free to
have large families of their own rather than adopt destitute
children from overseas, infertile couples must also be free to
do what they can to have their own large families.” (537)
…
7.
IVF allows increased male control over reproduction
and hence threatens the status of women in the
community
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Women have been actively involved in developing IVF
IVF was developed in part because of the demands of infertile
couples – often it is the woman who is most distressed
Even if ectogenesis is developed, this should be embraced as
an expansion of women’s choices rather than as an expansion
of male control; it could remove the final biological barrier to
true equality
Note: also raised in Sherwin’s article
Women and IVF
“What is the relationship between IVF and women’s
oppression?”
Sherwin argues that IVF is morally problematic because:
1.
Patriarchal Social Conditioning: ‘Breeders’
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Why do couples have such a strong desire or ‘need’ for
children of their own? Assumed to be a natural desire or
need, but…
Women are socially conditioned to believe that they are
only ‘true’ women if they bear children – the desire or
‘need’ for genetically related children is, at least in part,
socially and culturally constructed
IVF only adds to the inescapability of this conditioning – it
further entrenches these values
Objections?
Women and IVF
2. Decrease in Autonomy
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When other opportunities for fulfillment, self-worth, intimacy, and
accomplishment are not present in women’s lives (meaningful jobs
and relationships/friendships, for example), having children becomes
the one outlet for these desires. Providing yet another way for
women to have children (while the social conditions under which
women are employed in lower-paying and less satisfying jobs is
unchanged) is problematic
IVF looks like an increase in reproductive autonomy but actually
represents a decrease in reproductive autonomy if you take the
context of these decisions seriously
Offering more choices does not always mean increasing autonomy
– Examples: PAS/euthanasia and the elderly, Cochlear Implants, Prenatal
Genetic Testing
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Objections?
Women and IVF
3.
Continued Medicalization of Pregnancy and Birth
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Technologies applied to pregnancy and birth (scheduled
doctor appointments throughout pregnancy, forceps, lab
coats, masks, bright lights, labour timelines, episiotomies,
caesareans, fetal heart monitors)
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Increases outside control of women’s bodies
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These controls have in the past often become coercive and
contrary to the interests of women
Many recently proven ineffective in top quality studies
Shifts power away from the woman
Decreases autonomy and self-esteem
Objections?
Surrogacy
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A method of assisted reproduction
“Surrogacy refers to an arrangement whereby a woman
agrees to become pregnant for the purpose of gestating and
giving birth to a child for others to raise. She may be the
child's genetic mother or not, depending on the type of
arrangement agreed to.” - Wikipedia
The surrogate may also be referred to as a ‘contract mother’
or ‘gestational carrier’
Chosen by gay male couples, infertile couples, busy working
couples…
Surrogacy Relationships
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Commercial / Altruistic
Traditional Surrogacy – AI + gestation
Gestational Surrogacy – IVF + gestation
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Parenthood:
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– Genetic
– Guardian
– Gestational (women)
Main Argument For Surrogacy
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Autonomy
– Increased choice and control
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Option for couples who may have no other means of
having children
Option of employment for women willing to be
surrogates
Selling Ourselves?
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SELLING:
– Car
– Hair
– Blood
– Sperm
– Egg
– Parts of organs (ex// liver,
bone marrow)
– Organs (ex// kidney, lung)
– Baby
– Child
– Yourself (into slavery)
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RENTING/LEASING:
– Car
– Mental labour (workplace)
– Physical labour (workplace)
– Sexual organs
(prostitution)
– Uterus (surrogacy)
Slavery
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“Surrogacy is like slavery in the
absence of reciprocity, in the fact
that one person becomes what
Aristotle called an ‘animated tool’
of another, serving simply as a
means to another’s end” (In
Murray, 547)
Baby M
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Appendix, case 40 (699)
1985 Commercial Surrogacy Agreement
Baby M born March 1986
Mary Beth Whitehead (married with 2 children already) – traditional surrogacy
William Stern – married to Elizabeth Stern (MS)
$10,000 – $1,000(>5 months) - $0 (<5 months)
MBW had emotional attachment to baby & didn’t want to give the baby up
MBW fled the state with the baby
Changed location and remained hidden for 4 months
Eventually discovered and baby was returned to the Sterns
Trial 1 – contract ruled to be valid, MBW’s parental rights were terminated,
sole custody was awarded to William Stern, adoption by Elizabeth Stern was
authorized
Trial 2 (New Jersey Supreme Court)
– Declared contract invalid and unenforceable.
– In the end, on grounds of best interests, custody awarded to Sterns
– But Mary Beth Whitehead’s parental rights and visitation were restored
– 4 main concerns of NJ Supreme Court:
New Jersey Supreme Court
Concerns with Replies (Steinbock)
1.
–
Surrogate is not in a position to make an informed decision
to surrender her child (paternalism)
Surrogate may underestimate emotional and psychological distress of separation
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2.
Reply: not good grounds for limiting autonomy
Risk of psychosocial harm to the child
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Reply: speculative
3.
Commercial surrogacy contracts are tantamount to baby
selling*
4.
Commercial surrogacy contracts allow the rich to exploit the
poor*
*2 Main Concerns with Surrogacy
1.
Commercialization of children
2.
Exploitation of women who act as surrogates
1. Commercialization
Murray:
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Family relationship
– Nurturing, affection, trust, intimacy
– Unconditional acceptance, unchosen obligations
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Commercial relationship
– Exchange of goods and services for money
– Control, choice, personal preference
– Contracts
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What is the impact of allowing commercial relationships to enter the
realm of the family?
Selling Children
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Usually thought to be wrong because:
1.
Children have intrinsic moral worth and as such cannot
be bought or sold
2.
Consequences for children would be bad
OR (Murray’s proposal):
3.
Decreases human flourishing – which is best achieved
within stable loving families and in warm, caring
(noncommercial) relationships
Murray
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“Given the sort of creatures we humans are, our
patterns of psychosocial development, our needs at
different stages of our lives – given these facts, certain
values, institutions, and practices support our mutual
flourishing better than others. Specifically, the values of
the marketplace are ill suited for nurturing the values,
institutions, and practices that support the flourishing of
children and adults within families.” (548)
Altruistic or gift surrogacy is acceptable as long as it is
contributing to family values
Murray
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Sperm ‘donors’ who are paid are really sperm
‘vendors’
Egg ‘donors’/’vendors’ – but much riskier
– Compensation just for time (approx. 56 hours)?
Inconvenience? Risk? Egg?
2. Exploitation
When one party takes
advantage of another’s
economic need to secure
something for considerably less
than its value
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What is the price of a baby?
In paid surrogacy, something
‘priceless’ is received in exchange
for a modest amount of money
Steinbock
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Surrogacy is not intrinsically exploitative
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It is just a matter of regulations and guidelines
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Allow payment only for medical expenses (as in
adoption) and with carefully structured contracts
Murray’s Slippery Slope
Concerns
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If we discuss bioethical issues only in terms of choice and
control:
– Cloning human embryos, then cloning human embryos,
freezing them, and implanting them in someone else, then
implanting an aborted fetus’s ovary, with its millions of
yet-unripe eggs, into a woman’s body, so that she might
become pregnant with that fetus’s ova (550)
– Surrogacy for convenience?
Summary
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IVF
– Singer (for)
– Sherwin (against)
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Selling the body & surrogacy
– Baby M Case
– Murray (~against)
– Steinbock (~for)
Looking Ahead…
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Research Ethics
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*ESSAY 2 DUE in tutorial this Wednesday*
Contact
Prof. Kirstin Borgerson
Room 359S Munk Centre
Office Hours: Tuesday 3-5pm and by appointment
Course Website: www.chass.utoronto.ca/~kirstin
Email: [email protected]