Artificial gametes: perspectives of geneticists, ethicists and representatives of potential users

Several threads of research towards developing artificial gametes are ongoing in a number of research labs worldwide. The development of a technology that could generate gametes in vitro has significant potential for human reproduction, and raises a lot of interest, as evidenced by the frequent and extensive media coverage of research in this area. We have asked researchers involved in work with artificial gametes, ethicists, and representatives of potential user groups, how they envisioned the use of artificial gametes in human reproduction. In the course of three focus groups, the participants commented on the various aspects involved. The two recurring themes were the strength of the claim of becoming a parent genetically, and the importance of responsible communication of science. The participants concurred that (a) the desire or need to have genetic offspring of one's own does not warrant the investment of research resources into these technologies, and that (b) given the minefield in terms of moral controversy and sensitivity that characterises the issues involved, how information is communicated and handled is of great importance.

Uterus transplantation: ethical and regulatory challenges

Moving forward rapidly in the clinical research phase, uterus transplantation may be a future treatment option for women with uterine factor infertility, which accounts for three per cent of all infertility in women. This new method of treatment would allow women, who currently rely on gestational surrogacy or adoption, to gestate and birth their own genetic offspring. Since uterus transplantation carries significant risk when compared with surrogacy and adoption as well as when compared with other organ transplants, it requires greater justification because its goals are quality of life, not life-saving, in their scope. It is important to address questions regarding the physical, psychosocial and ethical risks and benefits of uterus transplantation for all three parties involved--the patient, the donor and the potential child--as well as discuss the regulatory implications as research on uterus transplantations moves forward.

Ethical considerations, safety precautions and parenthood in legalising mitochondrial donation

This article outlines some of the main ethical considerations specifically relating to legalisation of mitochondrial donation. Safety requirements, were the technique to be legalised, are then discussed, followed by an exploration of parenthood in the context of mitochondrial donation. It is concluded that there are no ethical objections specifically relating to the legalisation of mitochondrial donation, but that various safety precautions must be established prior to its use, including the availability of relevant medical information about the mitochondrial donors to any resultant children. It is also found that introduction of this technique would not necessitate modifications to current British legal definitions of parenthood. However, it is clear that societal attitudes in this area are changing, and it is recommended that this opportunity be taken to review concepts of parenthood, particularly the number of parents a child may have at one time.

Assessing child welfare under the Human Fertilisation and Embryology Act 2008: a case study in medicalisation?

This article reports on a study with staff working in assisted conception clinics in the UK about making welfare of the child (WOC) assessments pre-conception. This aspect of infertility treatment is obligatory under section 13(5) of the Human Fertilisation and Embryology Act, which was amended in 2008. The aim of the study was to find out how this change to the law had impacted on practice. In describing what we found, we also make a contribution to scholarship about the medicalisation of reproduction. S13(5) has often been discussed as a prime example of medicalisation, giving clinics power to grant or deny access to treatment on child welfare grounds, encompassing far more than purely clinical considerations. Yet, while such medicalisation may be entrenched in the law, our findings suggest this power is used with a very light touch. Further, while our interviewees offered near-universal support for the need to consider child welfare, this is now justified by concerns that address not only family form (e.g. the need for a father figure) but also the quality of interactions between parents and children. In this light we suggest that the concept of medicalisation may offer a rather blunt tool for understanding a far more complex reality.

Making sense of child welfare when regulating human reproductive technologies

Policy-makers have attempted to frame the ethical requirements that are relevant to the creation of human beings via reproductive technologies. Various reports and laws enacted in New Zealand, Canada, Australia, and Britain have introduced tests for how we should weigh child welfare when using these technologies. A number of bioethicists have argued that child welfare should be interpreted as a "best interests" test. Others have argued that there are ethical reasons why we should abandon this kind of test. I will argue that at least some of the relevant policy can be interpreted as requiring those wishing to exercise their procreative liberty to have a reasonable plan to care and nurture any resulting child, thereby respecting the internal preconditions of that liberty. This interpretation of child welfare requirements answers some of the ethical worries about a child welfare test.

[Public health ethics and reproduction]

Medical progress has enabled achievements that were not even thinkable earlier but at the same time society and public health have had to face new challenges. What are we ready to accept in the area of human reproduction? This paper aims at ethical analysis of Bulgarian laws on reproduction. The abortion debate nowadays has got new dimiension focusing not that much on its moral acceptability but rather on the acceptable indications for its performance. Is it ethical to perform abortion in case of undesired gender of the embryo or genetic malformations? Lots of moral issues mark the area of assisted reproduction which is due to the separation of the reproductive functions (ova, sperm and embryo donation, surrogacy), fragmentation of motherhood and fatherhood, differentiation of biological and social parenthood. Defining limits of acceptable interference or non-interference in human reproduction will never be easy, but dynamics of moral judgment shouldn't bother us. The rigidity of moral norms is what should be alarming because it threatens procreative autonomy.

Clinical and ethical implications of mitochondrial gene transfer

Inherited diseases caused by mitochondrial gene (mtDNA) mutations affect at least 1 in 5000-10,000 children and are associated with severe clinical symptoms. Novel reproductive techniques designed to replace mutated mtDNA in oocytes or early embryos have been proposed to prevent transmission of disease from parents to their children. Here we review the efficacy and safety of these approaches and their associated ethical and regulatory issues.

[Assisted reproductive technologies and ethics]

Since the first birth after in vitro fertilization more than 5 million of IVF babies are born in the world. Assisted reproductive technologies captivate the public, they allow maternity without ovary (oocyte donation), without uterus (surrogate mother), paternity without spermatozoids (sperm donation), parentality without limits of age, parentality after death and homoparentality. These technologies arise a lot of ethics questions, the problem is that the answers are not the same all-round the world, laws are based on morals, beliefs, faiths, and convictions. Theses variations arise themselves questions on the value of these non-universal answers.

Misconduct in third-party assisted reproduction: a committee opinion

Physicians who are told or discover information that would be material to another party's participation in an assisted reproductive technology (ART) arrangement (such as lawyer's, donor's, gestational carrier's, or intended parent's) should encourage disclosure to that party. In some instances, it is ethically and legally permissive for the physician to either disclose material information to an affected party or to transfer care of a patient to another willing provider. In all cases involving the legal status or rights of the parties, referral to legal professionals is advised.

Delayed childbearing: determining responsibilities for prime gamete quality

Delayed parenting affects fertility in women and in men, and cryopreservation of oocytes and sperm is becoming the latest trend as a solution for those who want or need to postpone procreation, in an attempt to avoid the damage medical conditions or time itself produces in gametes. Although "social freezing" is considered legitimate, its ethical and social aspects are in need of an overdue medical, public and legal debate. Assisted reproduction and cryopreservation, in combination with womb outsourcing, have opened the door to biological ectogenesis and the subsequent question of whether delayed childbearing means we should formally separate procreation from sexual activity. This article briefly summarizes what cryotechniques are capable of presently and in the near future, to separate fact from fiction. It names the implications for and discusses the practically virgin subject of the underlying responsibilities of delayed parenting techniques towards the child-to-be-not only the unborn but also the not-yet-conceived child. Considering the medical, economic, legal and social consequences of these rapidly growing developments in reproduction, several reasons point at the need to formally separate procreation from sexual activity, specifying responsibilities in the first while respecting personal choice in the second.

Numerical identity: the creation of tri-parental embryos to correct inherited mitochondrial disease

Inherited mitochondrial disorders affect between 1 in 5000 to 1 in 8000 people. These are a heterogeneous group of maternally-inherited disorders, with an array of outcomes such as heart and liver failure, defects in energy metabolism, blindness, deafness, loss of motor skills and premature death. Recently the Human Fertilisation and Embryology Authority provided advice to the UK Government to permit the use of enucleated donated oocytes with normal (wild-type) mitochondria (a currently prohibited IVF technique) to be used as recipients of nuclear DNA from intending mothers to overcome transmission of mitochondrial disorders. In this short communication we present the basis for this radical new IVF technology, and discuss the implications for its use both in the context of treating a group of inherited disorders and the current New Zealand IVF legislation.

Conceptualising a child-centric paradigm : do we have freedom of choice in donor conception reproduction?

Since its inception, donor conception practices have been a reproductive choice for the infertile. Past and current practices have the potential to cause significant and lifelong harm to the offspring through loss of kinship, heritage, identity, and family health history, and possibly through introducing physical problems. Legislation and regulation in Australia that specifies that the welfare of the child born as a consequence of donor conception is paramount may therefore be in conflict with the outcomes. Altering the paradigm to a child-centric model, however, impinges on reproductive choice and rights of adults involved in the process. With some lobby groups pushing for increased reproductive choice while others emphasise offspring rights there is a dichotomy of interests that society and legislators need to address. Concepts pertaining to a shift toward a child-centric paradigm are discussed.

[Being a family today - ethics for assisted reproductive techniques]

Currently in France, all the children born as a result of an assisted reproduction procedure, represent 2.5% of all births. Although this proportion is not high, it is not to be neglected, particularly with regard to the sociological issues raised by assisted reproduction technologies (ART) - i.e. removing anonymity of gamete donation, post mortem insemination, ART access to single women and gay couples, surrogacy - to name four of the most prominent debates. What is new with ART is that a new therapeutic target of medicine is being developed, in other words procreation. Now it is no longer necessary for a man and a woman to resort to sex to have a child. This is a profound questioning of the representation of what appeared to be intangible, with some sort of divine aura. How, in this context, developing an ethics for ART? From a fethnographic field survey, we show here how this ethos of ART develops and how, therefore, we consider the multiple ways of being a family today.

Honeymoon, medical treatment or big business? An analysis of the meanings of the term "reproductive tourism" in German and Israeli public media discourses

BACKGROUND/INTRODUCTION

Infertile couples that travel to another country for reproductive treatment do not refer to themselves as "reproductive tourists". They might even be offended by this term. "Tourism" is a metaphor with hidden connotations. We will analyze these connotations in public media discourses on "reproductive tourism" in Israel and Germany. We chose to focus on these two countries since legal, ethical and religious restrictions give couples a similar motivation to travel for reproductive care, while the cultural backgrounds and conceptions of reproduction are different.

RESULTS

Our research shows that the use of the metaphor "reproductive treatment" and its hidden messages depends on the writers' intention and the target population. Although the phenomenon of patients travelling for reproductive treatment can fit into the definitions of tourism, the term emphasizes aspects that do not reflect patients' reality. In both the German and the Israeli public media debate the term "reproductive tourism" is either used to criticize the economic aspects of the phenomenon or to attract patients as potential clients.

CONCLUSIONS

Ethicists should be cautious when borrowing metaphors like "reproductive tourism" from the public debate. Our findings support Penning's suggestion to use instead an unloaded term like cross-border reproductive care to describe the phenomenon in a more neutral way and to make it explicit whenever criticism is necessary.

Should there be a female age limit on public funding for assisted reproductive technology?

Should there be a female age limit on public funding for assisted reproductive technology (ART)? The question bears significant economic and sociopolitical implications and has been contentious in many countries. We conceptualise the question as one of justice in resource allocation, using three much-debated substantive principles of justice-the capacity to benefit, personal responsibility, and need-to structure and then explore a complex of arguments. Capacity-to-benefit arguments are not decisive: There are no clear cost-effectiveness grounds to restrict funding to those older women who still bear some capacity to benefit from ART. Personal responsibility arguments are challenged by structural determinants of delayed motherhood. Nor are need arguments decisive: They can speak either for or against a female age limit, depending on the conception of need used. We demonstrate how these principles can differ not only in content but also in the relative importance they are accorded by governments. Wide variation in ART public funding policy might be better understood in this light. We conclude with some inter-country comparison. New Zealand and Swedish policies are uncommonly transparent and thus demonstrate particularly well how the arguments we explore have been put into practice.

Access to assisted reproductive technologies in France: the emergence of the patients' voice

Is there any ethical justification for limiting the reproductive autonomy and not make assisted reproductive technologies available to certain prospective parents? We present and discuss the results of an interdisciplinary clinical ethics study concerning access to assisted reproductive technologies (ART) in situations which are considered as ethically problematic in France (overage or sick parents, surrogate motherhood). The study focused on the arguments that people in these situations put forward when requesting access to ART. It shows that requester's arguments are based on sound ethical values, and that their legitimacy is at least as strong as that of those used by doctors to question access to ART. Results reveal that the three implicit normative arguments that founded the law in 1994, which are still in force after the bioethics law revision in July 2011-the welfare of the child, the illegitimacy of a "right to a child," and the defense of the so called "social order"-are challenged on several grounds by requesters as reasons for limiting their reproductive autonomy. Although these results are limited to exceptional situations, they are of special interest insofar as they give voice to the requesters' own ethical concerns in the ongoing political debate over access to ART.

Law, bioethics and practice in France: forging a new legislative pact

In France, bioethics norms have emerged in close interaction with medical practices. The first bioethics laws were adopted in 1994, with provisions for updates in 2004 and most recently, in 2011. As in other countries, bioethics laws indirectly refer to certain fundamental values. The purpose of this paper is threefold. First, I shall briefly describe the construction of the French bioethics laws and the values they are meant to protect. Secondly, I will show that the practice of clinical ethics, as reported in a few studies on ART, living organ donation and PGD, challenge the role attributed to doctors as "gatekeepers" of those fundamental values. Thirdly, I will suggest that the quality of medical practices would improve if the law focused on strengthening the tacit pact between doctors and patients, rather than putting doctors in charge of enforcing societal values. Doctors, for their part, would limit their role to what they can do best: provide sufficient patient support and safe care. Against those who argue that we should dispense with bioethics laws altogether, I hold that the laws are useful in order to limit the development of abusive practices. However, a new legislative approach should be adopted which would a positive presumption in favor of patients' requests.

The French bioethics debate: norms, values and practices

In 1994, France passed bioethics laws regulating assisted reproductive technologies, organ donations and prenatal diagnosis. These laws were based upon a few principles considered as fundamental: the anonymity and gratuity of all donations concerning the elements of the human body, free and informed consent, and the interdiction of all commercial transactions on the human body. These laws have been the object of heated debates which continue to this day. On the basis on a few clinical ethics studies conducted by the Center for clinical ethics at the Cochin Hospital in Paris, the articles presented in this special issues explore several aspects of the bioethics debate, and relate it to the more general question of the complex relationship between norms, practices and values.

The ethics of uterus transplantation

Human uterus transplantation (UTx) is currently under investigation as a treatment for uterine infertility. Without a uterus transplant, the options available to women with uterine infertility are adoption or surrogacy; only the latter has the potential for a genetically related child. UTx will offer recipients the chance of having their own pregnancy. This procedure occurs at the intersection of two ethically contentious areas: assisted reproductive technologies (ART) and organ transplantation. In relation to organ transplantation, UTx lies with composite tissue transplants such as face and limb grafts, and shares some of the ethical concerns raised by these non-life saving procedures. In relation to ART, UTx represents one more avenue by which a woman may seek to meet her reproductive goals, and as with other ART procedures, raises questions about the limits of reproductive autonomy. This paper explores the ethical issues raised by UTx with a focus on the potential gap between women's desires and aspirations about pregnancy and the likely functional outcomes of successful UTx.

Expanding access to testicular tissue cryopreservation: an analysis by analogy

Researchers are developing a fertility preservation technique--testicular tissue cryopreservation (TTCP)--for prepubescent boys who may become infertile as a result of their cancer treatment. Although this technique is still in development, some researchers are calling for its widespread use. They argue that if boys do not bank their tissue now, they will be unable to benefit from any therapies that might be developed in the future. There are, however, risks involved with increasing access to an investigational procedure. This article examines four methods of expanding access to TTCP: (1) expansion of institutional review board (IRB)-approved research trials; (2) offering TTCP as an innovative procedure in hospitals; (3) offering TTCP as a standard practice in hospitals; and (4) commercialization of TTCP. The ethical and practical implications of each are evaluated through a comparison with umbilical cord blood banking (UCBB), a technology that has achieved widespread use based on similar claims of future benefit.

Ethical quandaries in gamete-embryo cryopreservation related to oncofertility

While cancer rates continue to increase, therapy has dramatically decreased the mortality rates. The increased efficacy of current therapies may unfortunately have profound toxic effects on gamete function in both adolescent and reproductive age groups, with infertility as an expected consequence of cancer therapy. Significant progress in the advancement of fertility preservation therapies provides realistic options for future fertility in cancer survivors. However, a number of challenging issues need to be considered when presenting fertility preservation options. This overview highlights some of these considerations including religious-cultural-ethical values, access to care and cost of services, developmental capacity and consent, and posthumous reproduction.

[The right to human reproduction. Should surrogate maternity be allowed?]

Is addressed in this work if you can accept that in Spain a reproductive rights through the use of assisted reproductive techniques, especially when the client is a single woman and when the baby has undergone a substitution pregnancy or surrogacy, regardless of those who have come to this possibility, which still continues to be considered without any efficacy in the rules governing the matter.

Assisted reproductive technologies: advances in medical practice or human subject research?

Although human subject research is regulated by federal agencies, the differences between research and innovative clinical practice are often blurred. Research and innovative practices share the similar goals of obtaining additional knowledge and improving medical treatment. Research, however, is more specifically defined as "a systematic investigation, including research development, testing and evaluation, designed to develop or contribute to generalizable knowledge." Aprocedure consistent with this definition is subject to distinct federal regulations and other ethical procedural safeguards. When unregulated innovative practices, not neatly fitting within this definition of research, are first implemented, safeguards do not necessarily exist because use of these procedures is primarily guided by individual physician judgment. Recognizing that the application of innovative advancements in ART may very well benefit numerous prospective infertile patients and may initially appear to be safe and effective, these new and novel procedures may be associated with yet unknown long-term risks and safety concerns unless more formal scientific study is conducted to support efficacy and safety.

Bioethical dilemmas of assisted reproduction in the opinions of Polish women in infertility treatment: a research report

Infertility Accepted treatment is replete with bioethical dilemmas regarding the limits of available medical therapies. Poland has no legal acts regulating the ethical problems associated with infertility treatment and work on such legislation has been in progress for a long time, arousing very intense emotions in Polish society. The purpose of the present study was to find out what Polish women undergoing infertility treatment think about the most disputable and controversial bioethical problems of assisted reproduction. An Attitudes towards Bioethical Problems of Infertility Scale was constructed specifically for this study. Items were taken from the Bioethics Bills currently under discussion in Polish Parliament (Seym). 312 women were enrolled in the study. Women experiencing infertility favoured more liberal legislation. Participants disagreed, for example, with the following regulations: prohibition of embryo freezing, prohibition of preimplantation genetic diagnosis of embryos, age limits for women using in vitro fertilisation and prohibition of in vitro fertilisation for single women. The opinions of patients undergoing infertility treatment are an important voice in the Polish debate on the Bioethics Bills.

Orphaned at conception: the uncanny offspring of embryos

A number of advances in assisted reproduction have been greeted by the accusation that they would produce children 'without parents'. In this paper I will argue that while to date these accusations have been false, there is a limited but important sense in which they would be true of children born of a reproductive technology that is now on the horizon. If our genetic parents are those individuals from whom we have inherited 50% of our genes, then, unlike in any other reproductive scenario, children who were conceived from gametes derived from stem cell lines derived from discarded IVF embryos would have no genetic parents! This paper defends this claim and investigates its ethical implications. I argue that there are reasons to think that the creation of such embryos might be morally superior to the existing alternatives in an important set of circumstances.

Donating embryos to stem cell research

This paper is based on linked qualitative studies of the donation of human embryos to stem cell research carried out in the United Kingdom, Switzerland, and China. All three studies used semi-structured interview protocols to allow an in-depth examination of donors' and non-donors' rationales for their donation decisions, with the aim of gaining information on contextual and other factors that play a role in donor decisions and identifying how these relate to factors that are more usually included in evaluations made by theoretical ethics. Our findings have implications for one factor that has previously been suggested as being of ethical concern: the role of gratitude. Our empirical work shows no evidence that interpersonal gratitude is an important factor, but it does support the existence of a solidarity-based desire to "give something back" to medical research. Thus, we use empirical data to expand and refine the conceptual basis of bioethically theorizing the IVF-stem cell interface.

Welcome to the wild west: protecting access to cross border fertility care in the United States

As has been the case with other types of medical tourism, the phenomenon of cross border fertility care ("CBFC") has sparked concern about the lack of global or even national harmonization in the regulation of the fertility industry. The diversity of laws around the globe leads would-be parents to forum shop for a welcoming place to make babies. Focusing specifically on the phenomenon of travel to the United States, this Article takes up the question of whether there should be any legal barriers to those who come to the United States seeking CBFC. In part, CBFC suffers from the same general concerns raised about the use of fertility treatment in general, but it is possible to imagine a subset of arguments that would lead to forbidding or at least discouraging people from coming to the United States for CBFC, either as a matter of law or policy. This paper stands in opposition to any such effort and contemplates the moral and ethical concerns about CBFC and how, and if, those concerns warrant expression in law. Part I describes the conditions that lead some couples and individuals to leave their home countries to access fertility treatments abroad and details why the United States, with its comparatively liberal regulation of ART, has become a popular CBFC destination for travelers from around the world. Part II offers and refutes arguments supporting greater domestic control over those who seek to satisfy their desires for CBFC in the United States by reasserting the importance of the right of procreation while also noting appropriate concerns about justice and equality in the market for babies. Part III continues the exploration of justice by investigating the question of international cooperation in legislating against perceived wrongs. This Part concludes that consistent legislation across borders is appropriate where there is consensus about the wrong of an act, but it is unnecessary and inappropriate where there remain cultural conflicts about certain practices—in this case assisted reproduction.

Legal perspectives on cross-border reproductive care

Global cross-border reproductive care (CBRC), and the challenges accompanying it, are here to stay. A recent issue of this journal devoted to CBRC provides an extraordinary array of insights into multiple facets, with a focus on the legal dimensions of practices by restrictive countries such as Turkey and Italy. The articles identify restrictive laws that challenge and create vulnerabilities for both citizens and providers involved in CBRC, and call instead for more modest and nuanced legislation and the closing paper presents a thoughtful and ambitious outline for a future research agenda. This commentary reflects on the implications of these legal dimensions, including their applicability to countries with more permissive CBRC policies, discusses three specific examples of legal concerns that have arisen in the USA and identifies numerous legal issues meriting future study. Together with the nuanced, more modest legislation recommended for restrictive countries, consistent legal and judicial principles for CBRC in permissive countries would respect varying perspectives on family building while attempting to address a central legal concern of CBRC, the protection of families, third-parties and providers. Any future agenda should include research and recommendations on the legal dimensions of CBRC in both restrictive and permissive countries.