On new reproductive technologies and family ethics: pre-implantation genetic diagnosis for sibling donor in Israel and Germany

Mapping ethical, legal, and social implications (ELSI) of preimplantation genetic testing (PGT)

PURPOSE

Preimplantation Genetic Testing (PGT) has attracted considerable ethical, legal, and social scrutiny, but academic debate often fails to reflect clinical realities.

METHODS

Addressing this disconnect, a review of 506 articles from 1999 to 2019 across humanities and social sciences was conducted to synthesize the Ethical, Legal, and Social Implications (ELSI) of PGT. This review mined PubMed, WoS, and Scopus databases, using both MeSH terms and keywords to map out the research terrain.

RESULTS

The findings reveal a tenfold increase in global research output on PGT's ELSI from 1999 to 2019, signifying rising interest and concern. Despite heightened theoretical discourse on selecting "optimal" offspring, such practices were scarcely reported in clinical environments. Conversely, critical issues like PGT funding and familial impacts remain underexplored. Notably, 86% of the ELSI literature originates from just 12 countries, pointing to a research concentration.

CONCLUSION

This review underscores an urgent need for ELSI research to align more closely with clinical practice, promoting collaborations among ethicists, clinicians, policymakers, and economists. Such efforts are essential for grounding debates in practical relevance, ultimately steering PGT towards ethical integrity, societal acceptance, and equitable access, aiming to harmonize PGT research with real-world clinical concerns, enhancing the relevance and impact of future ethical discussions.

The emergence of temporality in attitudes towards cryo-fertility: a case study comparing German and Israeli social egg freezing users

Assistive reproductive technologies are increasingly used to control the biology of fertility and its temporality. Combining historical, theoretical, and socio-empirical insights, this paper aims at expanding our understanding of the way temporality emerges and is negotiated in the contemporary practice of cryopreservation of reproductive materials. We first present an historical overview of the practice of cryo-fertility to indicate the co-production of technology and social constructions of temporality. We then apply a theoretical framework for analysing cryobiology and cryopreservation technologies as creating a new epistemic perspective interconnecting biology and temporality. Thereafter, we focus on the case of 'social egg freezing' (SEF) to present socio-empirical findings illustrating different reproductive temporalities and their connection to the social acceptance of and expectations towards the practice. SEF is a particularly interesting case as it aims to enable women to disconnect their reproductive potential from their biological rhythms. Based on 39 open interviews with Israeli and German SEF users, the cross-cultural comparative findings reveal three types of attitudes: postponing motherhood/reproductive decisions (German users); singlehood and "waiting" for a partner (Israeli and German users); and the planning of and hope for multiple children (Israeli users). For theory building, this analysis uncovers temporality formations embedded in gender and reproductive moral values; including the 'extended present', 'waiting', and 'reproductive futurism'. We conclude by discussing the contribution of our findings by advancing the theoretical framework of 'cryopolitics' highlighting the theoretical implications and importance of gendered and cultural imaginaries (re)constructing medical technological innovations and related temporalities.

What can European Principlism Teach about Public Funding of IVF? The Israeli Case

Fertility treatments, which are part of "assisted reproductive technologies" (ART), mainly undertaken through in vitro fertilization (IVF), offer the opportunity to infertile couples to conceive. IVF treatments are undertaken in Israel in significantly higher numbers than in the rest of the world. As such, Israel provides an important case-in-point for examining the validity of the actual claims used to justify the more generous public funding of IVF treatments at the policy level. In this article, we utilize an analytical philosophy approach to conduct this examination. First, we highlight two fundamental concepts that were used at the Israeli public policy level in order to justify the generous public funding of IVF treatments. These concepts are "emotional vulnerability" and the "worthlessness of the childless," where the latter emphasizes the infinite value of children. Then, by applying the perspective of the European model of Bioethical Principlism, and focusing the attention to these two concepts we show that these justifications are invalid. Specifically, it is suggested that these concepts are on the one hand both relying on and expressing the principles of vulnerability, dignity, and integrity; yet on the other hand, these concepts are also undermining the very principles of bioethics they are supposed to express and rely on. Based on this suggested criticism, we offer two "take home" messages informed by our analysis of the Israeli case, but reaching beyond it.

Comparing Germany and Israel regarding debates on policy-making at the beginning of life: PGD, NIPT and their paths of routinization

Definition

The routinization of prenatal diagnosis is the source of bioethical and policy debates regarding choice, autonomy, access, and protection. To understand these debates in the context of cultural diversity and moral pluralism, we compare Israel and Germany, focusing on two recent repro-genetic “hot spots” of such policy-making at the beginning of life: pre-implantation genetic diagnosis (PGD) and non-invasive prenatal genetic testing (NIPT), two cutting-edge repro-genetic technologies that are regulated and viewed very differently in Germany and Israel, reflecting different medicolegal policies as well as public and bioethical considerations.

Arguments

First, we compare policy-making in the context of PGD for HLA (human leukocyte antigen) typing, used to create sibling donors, approved in Israel under specific conditions while prohibited in Germany. Second, we compare policy-making in the context of NIPT, which came under fire in Germany, while in Israel there has been little public debate about it.

Conclusion

Both countries justify their contrasting policies as reflecting a concern for the well-being and care of the embryo/child, thus highlighting different concepts of embryo/child protection, (relational) autonomy, family relations, and the impact of religion and history on the promotion/protection of life. We use the juxtaposition of PGD and NIPT to highlight some inconsistencies in policies concerning the protection of extra- and intra-corporeal embryos. We conclude by drawing on the comparison to show how national variations exist alongside co-evolution.

Moving gender: Home museums and the construction of their inhabitants

Home museums in Israel and Germany produce a representational space in which the public figure, usually a ‘great man,’ is effectively ‘dragged home’ to the so-called private sphere so as to make the domestic worthy of musealization. Based on three years of ethnographic research in nine such museums (four in Israel and five in Germany), this article shows that when the sphere most identified with women is represented through the life and work of the men who lived there, the place of the wife and children is sidelined, belittled, and at times concealed. In representing famous persons through material space and objects in the private abode, museal techniques determine which specific domestic areas, such as the kitchen and the bedroom, become the prime location of telling stories about women who lived in the house. They provide a shared perspective for visitors who find the stories about the wives endearing, recognizing home through them.

Intersex Activists in Israel: Their Achievements and the Obstacles They Face

This article focuses on the dynamic between the medical policy on intersex bodies and intersex activists in Israel. Recently, in many countries changes have taken place in medical guidelines regarding intersex patients and laws that regulate medical practices and prohibit irreversible surgeries for intersex babies for cosmetic reasons and without the patient's consent. In Israel, intersex activists are limited by several factors. On the one hand, they are influenced by the achievements of intersex activism around the world but on the other, the pathologizing medical discourse and socio-medical practices, which include early diagnosis, early irreversible surgeries, and secrecy surrounding intersexed bodies, present obstacles to achieving bodily autonomy for intersex individuals and social recognition of different sex development. Nevertheless, intersex activists are attempting to find different social and media spaces in which to achieve public acknowledgement and future bodily autonomy for intersexed people and seeking medical professionals' cooperation. Recently, the Israeli Ministry of Health published a new circular for intersex/DSD patients, and while it does not clearly forbid irreversible surgeries, it provides information about the complexities of intersex people and their experience.

Time matters for intersex bodies: Between socio-medical time and somatic time

This article focuses on the dynamic relationships between time and intersex bodies that exist, on the one hand, in medical policy on intersex bodies and, on the other, in intersex people's subjective experiences. Time, from a sociological perspective, is a biosocial agent that establishes diagnostic practices, regulations, and treatment policy regarding intersex bodies. The systematic construction of timeframes by biomedical professionals aims to rapidly diagnose and treat intersex patients and is deeply rooted in the "dimorphic soma-gender order" (DMSGO), the imagined unified relationship of female bodies to femininity and male bodies to masculinity. From a socio-phenomenological perspective, I describe the concept of somatic time, which involves the relationship between time and the soma, the body's own particular clock and rhythms, according to which it grows, changes, and develops, and the body as a time capsule that stores experiences. I will illustrate the somatic time of intersex people and their subjective embodied experiences of the soma-gender relationship, and explore how their somatic time challenges biomedical timeframes. This qualitative study is based on narrative interviews with biomedical professionals, parents of intersex children, and intersex adults from Israel and Germany.

Saving or Subordinating Life? Popular Views in Israel and Germany of Donor Siblings Created through PGD

To explore how cultural beliefs are reflected in different popular views of pre-implantation genetic diagnosis for human leukocyte antigen match (popularly known as "savior siblings"), we compare the reception and interpretations, in Germany and Israel, of the novel/film My Sister's Keeper. Qualitative analysis of reviews, commentaries and posts is used to classify and compare normative assessments of PGD for HLA and how they reproduce, negotiate or oppose the national policy and its underlying cultural and ethical premises. Four major themes emanated from the comparison: loss of self-determination and autonomy; loss of dignity through instrumentalization; eugenics and euthanasia; and saving life. In both countries, most commentaries represented a dominant position, with a few negotiated positions. We also highlight the decoding of a relatively less explored bioethical aspect of My Sister's Keeper's narrative, namely the meaning of euthanasia. We conclude by discussing how the findings relate to attempts of providing cultural explanations for the regulation of HLA-PGD.

A cross-cultural analysis of posthumous reproduction: The significance of the gender and margins-of-life perspectives

The scholarly discussion of posthumous reproduction (PHR) focuses on informed consent and the welfare of the future child, for the most part overlooking cultural differences between societies. Based on a cross-cultural comparison of legal and regulatory documents, analysis of pivotal cases and study of scholarly and media discussions in Israel and Germany, this paper analyses the relevant ethical and policy issues, and questions how cultural differences shape the practice of PHR. The findings challenge the common classifications of PHR by highlighting the gender perspective and adding brain-dead pregnant women to the debate. Based on this study's findings, four neglected cultural factors affecting social attitudes towards PHR are identified: (i) the relationship between the pregnant woman and her future child; (ii) what constitutes the beginning of life; (iii) what constitutes dying; and (iv) the social agent(s) seeking to have the future child. The paper argues that PHR can be better understood by adding the gender and margins-of-life perspectives, and that future ethical and practical discussions of this issue could benefit from the criteria emerging from this cross-cultural analysis.

Attitudes Toward Pre-implantation Genetic Diagnosis (PGD) for Genetic Disorders Among Potential Users in Malaysia

While pre-implantation genetic diagnosis (PGD) is available and legal in Malaysia, there is an ongoing controversy debate about its use. There are few studies available on individuals' attitudes toward PGD, particularly among those who have a genetic disease, or whose children have a genetic disease. To the best of our knowledge, this is, in fact, the first study of its kind in Malaysia. We conducted in-depth interviews, using semi-structured questionnaires, with seven selected potential PGD users regarding their knowledge, attitudes and decisions relating to the use PGD. The criteria for selecting potential PGD users were that they or their children had a genetic disease, and they desired to have another child who would be free of genetic disease. All participants had heard of PGD and five of them were considering its use. The participants' attitudes toward PGD were based on several different considerations that were influenced by various factors. These included: the benefit-risk balance of PGD, personal experiences of having a genetic disease, religious beliefs, personal values and cost. The study's findings suggest that the selected Malaysian participants, as potential PGD users, were supportive but cautious regarding the use of PGD for medical purposes, particularly in relation to others whose experiences were similar. More broadly, the paper highlights the link between the participants' personal experiences and their beliefs regarding the appropriateness, for others, of individual decision-making on PGD, which has not been revealed by previous studies.

Exploring the positions of German and Israeli patient organizations in the bioethical context of end-of-life policies

Patient organizations are increasingly involved in national and international bioethical debates and health policy deliberations. In order to examine how and to what extent cultural factors and organizational contexts influence the positions of patient organizations, this study compares the positions of German and Israeli patient organizations (POs) on issues related to end-of-life medical care. We draw on a qualitative pilot study of thirteen POs, using as a unit of analysis pairs comprised of one German PO and one Israeli PO that were matched on the basis of organizational category. Bioethical positions that emanated from the interviews concerned advance directives--general views, recent legal framework, and formalization; as well as active and passive euthanasia, withholding and withdrawing of treatment, and physician-assisted suicide. In addition to the unifying, within-country impact of cultural factors, we found that constituency-based organizations and partner organizations in both countries often share common views, whereas disease-based support organizations have very heterogeneous positions. We conclude by discussing how organizational contexts provide a source of uniformity as well as diversity in the positions of POs.

"What the patient wants…": Lay attitudes towards end-of-life decisions in Germany and Israel

National legislation, as well as arguments of experts, in Germany and Israel represent opposite regulatory approaches and positions in bioethical debates concerning end-of-life care. This study analyzes how these positions are mirrored in the attitudes of laypeople and influenced by the religious views and personal experiences of those affected. We qualitatively analyzed eight focus groups in Germany and Israel in which laypeople (religious, secular, affected, and non-affected) were asked to discuss similar scenarios involving the withholding or withdrawing of treatment, physician-assisted suicide, and euthanasia. In both countries, respect for patient autonomy and patients' wishes to die with dignity found broad consent. Laypeople argued in favor of accepting such wishes when they were put down in an advance directive. Laypeople in non-religious groups in both countries argued on the basis of a respect for autonomy for the possibility of euthanasia in severe cases but, at the same time, cautioned against its possible misuse. National contrast was apparent in the moral reasoning of lay respondents concerning the distinction between withholding and withdrawing treatment. The modern religious laypeople in Israel, especially, argued strongly, on the basis of the halakhic tradition, against allowing the withdrawal of treatment in accord with a patient's wish. We conclude by discussing the emergent notion of shared responsibility and views of professional responsibility, which we connect through relevant cultural themes such as religion and national culture.

Selective Reproductive Technologies

From a historical perspective, selective reproduction is nothing new. Infanticide, abandonment, and selective neglect of children have a long history, and the widespread deployment of sterilization and forced abortion in the twentieth century has been well documented. Yet in recent decades selective reproduction has been placed under the aegis of science and expertise in novel ways. New laboratory and clinical techniques allow for the selective fertilization of gametes, implantation of embryos, or abortion of fetuses. Although they will often overlap with assisted reproductive technologies (ARTs), what we term selective reproductive technologies (SRTs) are of a more specific nature: Rather than aiming to overcome infertility, they are used to prevent or allow the birth of certain kinds of children. This review highlights anthropological research into SRTs in different parts of the world, discussing how selective reproduction engages with issues of long-standing theoretical concern in anthropology, such as politics, kinship, gender, religion, globalization, and inequality.

Egg freezing for age-related fertility decline: preventive medicine or a further medicalization of reproduction? Analyzing the new Israeli policy

In December 2009, the Israel National Bioethics Council (INBC) issued recommendations permitting egg freezing to prevent both disease- and age-related fertility decline. The INBC report forms the basis of Israel's new policy regarding egg freezing. This article analyzes the medical section of the INBC's recommendations, comparing it with guidelines formulated by medical regulatory bodies in Europe and the United States. Our findings suggest that the INBC's recommendations consider age-related fertility decline to be a medical problem, and hence treat the new technology favorably, as preventive medicine, which we perceive as another instance of medicalization. The technology's risks are downplayed by the INBC, unlike the positions of medical organizations in both Europe and the United States, which consider the new technology experimental. This may culminate in raising false hopes about women's possible late genetic motherhood leading to involuntary future childlessness.

Attitudes of social science students in Israel and Austria towards the belated twins scenario--an exploratory study

This article discusses results of a questionnaire survey of 156 university students in Israel and Austria examining reactions towards the Belated Twins scenario, which entails the artificial twinning of embryos of which one is immediately carried to term while the other one is born later. The scenario resembles a case of human reproductive cloning in terms of result (the creation of genetically identical individuals in a time-delayed manner) but it involves gamete fusion like "natural" reproduction. By means of qualitative text analysis we discuss the core themes mobilized both in support and opposition to the scenario. While Israeli and Austrian respondents held similar general attitudes (about half were in favour of legalizing Belated Twins, while about a third opposed it), they drew partly on different arguments to arrive at their conclusions. In both groups, uncertainty stemming from "novel" elements in the scenario was regularly interpreted as negatively exacerbating existing issues.

The intensive medical care of sick, impaired, and preterm newborns in Israel and the production of vulnerable neonatal subjectivities

Following reduction in mortality rates of term and preterm babies hospitalized in NICUs, neonataology refocused its concerns on the survivors' elevated risks of long-term health and developmental problems, thus turning the "intact survival" of hospitalized newborns into an equivalently desired moral and professional goal as their "survival." Based on ethnographic observations in an Israeli NICU ("pagia"), I suggest that the new moral practice has bearings on the construction of neonatal subjectivities. According to Jewish and Israeli laws, personhood is conferred on at birth. However, my findings indicate that in practice the question of "quality of life" often appears to be a stronger consideration than legal personhood when withdrawal of intensive therapies is discussed in the nursery. Consequently, the significance of the moment of birth to the construction of subjectivity is obscured. The construction of subjectivity as a progressively developed and irreversible category is challenged, and it becomes vulnerable.

Genetic testing of children for familial cancers: a comparative legal perspective on consent, communication of information and confidentiality

Genetic testing of children is the subject of ethical and legal debate. On the one hand, the literature emphasises the personal interests and rights of the individual child. On the other, the interests of the parents and the family as a whole are discussed. English law relies by and large on a patient-centred approach where the child has some say about his/her medical care. The view reflected in Anglo-American guidelines, more specifically, is that testing is potentially harmful and may compromise the child's autonomy and confidentiality. This explains the reluctance to submit children to predictive genetic testing. An analysis of Israeli law, however, reflects a different approach, where the benefit to the child is defined more widely. This accords with the general communitarian position adopted by Israeli law, a legal position that reflects the duality of Israeli society in simultaneously promoting both fundamental human rights and family ethics. In practice, however, there may be little difference, as children in both jurisdictions have access to similar genetic services.