Reproductive Ethics and New Reproductive Technologies Research Paper

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Reproductive Technologies

Assisted human reproductive technologies (ARTs) have become increasingly common in the mid to late twentieth century in most developed countries. Technological and theoretical advances together with pharmaceutical developments and improved practical techniques taken from gynecology, genetics, urology, and associated medical specialties have combined to enable treatment for individuals or couples experiencing infertility due to a wide range of causes. The ART market is predicted to grow as it provides a key solution to public health problems associated with declining birth rates in many countries, due both to increasing rates of unexplained infertility and lower fertility associated with delayed marriage and reproduction reflecting changes in work and lifestyle patterns. Although originally ARTs were available primarily in developed countries, as costs have decreased, some of the less complex technologies are now available in less technologically developed countries, particularly those with cultures that highly value biologically related children. However, ARTs bring with them a number of controversial ethical issues, including who should be permitted to access these technologies and for what indications, whether or not they are considered a regular part of medical care and hence covered by governmental or private insurance, and if they represent an effective public health strategy.

General Ethical Issues Associated With ARTs

There are a number of religious arguments typically raised against ARTs. Some Christian traditions claim that all ARTs are ethically impermissible because they separate the natural process of procreation from intercourse within marriage, which is seen as unnatural (for discussion, see Cahill and McCormick, 1987; Fisher, 1989). ARTs are also viewed as a threat to the concept of the family and to the dignity of human beings, particularly inasmuch as technology dominates the origin of the human being. Thus many of these critics argue both that reproduction should not be interfered with (e.g., by using contraception) and that technology should not be used to intervene in or to help to achieve reproduction. Other traditions emphasize the unnaturalness of ARTs. Some Confucian commentators claim that any nonconjugal reproduction weakens the blood ties between family members and leads to moral and social instability (Qiu, 2002). Aside from those writing from a particular religious perspective, there are other critics who do not oppose (married heterosexual) couples making autonomous decisions about reproduction such as using contraception, but who do not view ARTs or other unnatural arrangements as morally permissible (e.g., Marquis, 1989). Still others consider ARTs in relation to environmental ethics, arguing that infertile couples should adopt since the world is already overpopulated and that the desire to have a biologically related child is selfish (for a related argument, see McKibben, 1998). According to this reasoning, individual desires to have children should give way to broader concerns about population health and control.

Further ethical issues are raised by the selection criteria that are used to determine who receives ARTs. In many countries and clinics, these technologies are only made available for married heterosexual couples. Access to ARTs by unmarried (or de facto) couples and lesbian or single women is much more restricted, the latter being considered an instance of social rather than medical infertility. There have also been concerns about postmenopausal women using ARTs and donor eggs to conceive, and many clinics have rules limiting the provision of ARTs to women over a particular age (typically early to mid-forties) in part out of concerns for the welfare of the future child and relatively low success rates (Hope et al., 1995). Finally, particularly in public health-care systems where ARTs are freely available, screening criteria such as age are used to choose the best candidates (those with most likelihood of success) due to limited resources, notably donor sperm, or limits are placed on the number of cycles that can be undergone to attempt to achieve a pregnancy.

In some jurisdictions (e.g., most states in the United States), there is no requirement that insurance companies provide coverage for infertility treatments, which means that only the most affluent can afford to use ARTs. Where public funds are directed at research or treatment using ARTs, there are economic concerns about whether it is just to use considerable health resources to help a relatively small number of people conceive in what are typically overstretched public health-care systems. Some argue that resources might be better utilized for research into and prevention of the various causes of infertility and related population-based problems including environmental issues, rather than individualized clinical solutions. Further, there is considerable disquiet about support for ARTs in populations where evidence shows they are unlikely to be successful, for example older women.

Feminist scholars have expressed concerns about ARTs placing additional psychological, economic, and physical pressures on women to produce biologically related children (Sherwin, 1992; Donchin, 1996). They cite the problematic case of using ARTs to treat primary male infertility. This requires women to undergo onerous fertility treatments involving hyperstimulation of the ovaries and a series of surgical procedures despite the women themselves not being infertile. Further, they argue that infertility itself is a socially defined and interpreted category, rather than a natural disease category (Sherwin, 1992) and one that has been reinforced by a largely male-dominated medical profession. Most of these commentators do not deny that many women wish to have biologically related children, but they emphasize that the social and economic pressures associated with ARTs often are ignored. Others argue that ARTs have not been sufficiently well assessed, particularly with regard to their potential long-term negative effects on women’s health, especially due to the side effects of hyperstimulation (de Melo-Martin, 1998).

Artificial Insemination

Some of the simpler advanced reproductive technologies that do not require the involvement of medical professionals were traditionally adapted from animal husbandry for use in human reproduction, notably artificial insemination by donor (AID) or by husband/partner (AIH). The introduction of semen or concentrated specimens of spermatozoa into a woman’s reproductive tract by noncoital means can be successfully performed with instruments as simple as a turkey baster (Wikler and Wikler, 1991). AI is sometimes coupled with use of hormones to stimulate ovulation at the time of insemination to maximize the chances of fertilization occurring, although these drugs are associated with some risks to the women involved.

In recent years, fears about donor health status, risk of infection (HIV and otherwise), and legal issues (such as establishing paternity) have caused most AI to be performed in medical clinics under a physician’s supervision. Hence some critics note that this procedure has become unduly medicalized. In the past, some doctors avoided paternity issues by mixing sperm from several donors including the male partner, but recent advances in genetic technologies allow paternity testing using DNA and have resulted in clarification in many jurisdictions of the legal standing of children born from AI. Legal issues remain in some places, for instance with custody and adoption of AID children born to lesbian couples.

Some religious traditions do not consider AID to be ethically permissible as they hold it to be equivalent to adultery. Historically there has typically been considerable stigma associated with AID, and often information about the biological father (or even the fact that the child was produced using AID) was not revealed to children born using AID. However, in many countries recent changes in the law or court decisions have established that children born of AID have the right to information about their biological fathers once they are 18 years of age. This change is due in part to long-term psychosocial studies that have shown that there are considerable benefits to disclosure, as is the case with adopted children (Blyth, 1998; McWhinnie, 2000; Ethics Committee of the American Society of Reproductive Medicine, 2004). Following these changes, the rate of anonymous donation for AID programs has decreased dramatically in many countries, apparently because anonymity cannot be guaranteed once the child becomes an adult. In contrast, in the United States, some clinics have reported increased donor rates, apparently among those men who would be happy to have contact with their biologically related children in the future.

In Vitro Fertilization And Embryo Transfer

The first successful birth using in vitro fertilization and embryo transfer (IVF-ET) occurred in 1978. The British scientists involved, Patrick Steptoe and Robert Edwards, drew on embryological studies done for over 20 years in mice, rabbits, and other animals. The procedure involved laparoscopic aspiration of an egg during a woman’s natural cycle, followed by IVF using ejaculated sperm and transfer of the dividing embryo in its early stages into the woman’s uterus, hence creating what became known as a test tube baby. More generally in IVF-ET, eggs are harvested and mixed in Petri dishes either with donor sperm or with sperm from the male partner (if primary male infertility is not thought to be at issue), typically using the healthiest sperm to facilitate fertilization. Eggs may be obtained from the female partner being treated or donated by another woman (e.g., in cases of premature ovarian failure, genetic abnormalities, or reduced egg production due to advanced maternal age). Most women undergoing IVF-ET also have controlled ovarian hyper stimulation prior to aspiration of eggs to increase the number of eggs that are viable. Early fears that babies produced through IVF would be abnormal have not been substantiated. However, in many localities there is inadequate tracking of offspring and potential health problems, including their future reproductive health.

Depending on the clinic, the country, and the putative cause of infertility in the couple, different numbers of fertilized embryos are created and transferred. Improved methods recently have created higher success rates both in terms of the number of viable embryos that can be created as well as the likelihood of embryo implantation following transfer (the latter remains the major technological barrier to successful pregnancies via IVF). The result has been numerous cases of multiple gestations; however, due to the increased risks of low birth rate and other abnormalities associated with multiple births, selective reduction (i.e., termination) of one or more of the fetuses may be offered to the parents, which present difficult decisions, particularly for those opposed to termination. Consequently, many clinics have adopted more conservative approaches to the number of embryos created and transferred at any one time, and there are now laws or professional guidelines in some countries to limit the number of embryos that can be transferred during any one IVF cycle.

There are social, ethical, and legal issues associated with the status and disposition of embryos that are surplus to the needs of the individuals pursuing IVF. Excess or supernumerary embryos can be cryopreserved at a very early stage for later IVF cycles; most clinics allow limited storage but require destruction of embryos after a set period of time unless the embryos are donated to other infertile couples or under certain circumstances donated for stem cell or fertility research. In all of these cases, issues arise concerning the moral status of the embryo; some people who believe that the human embryo has the moral standing of a child or even adult human being (i.e., it is a person deserving of protection and respect) tend to favor donation to other infertile couples. Others who do not believe that personhood starts in these early stages are more likely to consider donating embryos for research or disposing of them.

One of the major ethical issues that has arisen with IVF relates to how clinics report success rates. Previously, clinics reported success in terms of pregnancies established, whereas clients typically were interested in the likelihood of taking home a baby and hence had unrealistic expectations. Standards have recently been developed by professional societies to standardize how this information is conveyed to clients, though some would claim that considerable empty rhetoric still surrounds the IVF industry and that clients are not always well informed.

IVF-ET can now be combined with preimplantation genetic diagnosis (PGD) techniques, which permit testing of embryos for genetic diseases and chromosomal abnormalities to allow selection and transfer only of unaffected embryos. This technique was originally developed as an alternative to prenatal diagnosis (and possibly termination for fertile couples with known genetic risks). However there are debates surrounding what types of tests using PGD should be offered, for instance whether embryos should be screened for only severe, early-onset disease conditions or if later onset conditions or nondisease conditions should be included (Robertson, 2003). The combination of PGD and human leukocyte antigen (HLA) typing (or tissue typing) allows couples to have an unaffected child who can serve as a donor for an ill sibling who has a medical condition requiring a hematopoietic stem cell transplant (preferably from a well-matched donor). The creation of these so-called savior siblings is viewed by some as morally well justified, particularly when the parents were already planning to have additional children (Fost, 2004).

IVF-ET theoretically also could be used to implant a cloned embryo. Human embryo clones could be created by taking an egg from a woman, extracting the nucleus, and leaving behind only the cytoplasm. The nucleus of a somatic (body) cell (from another person or the same woman who donated the original egg) is then extracted and inserted into the cytoplasm. Under the correct culture conditions, the entity created will start to divide normally, behaving like a naturally created embryo (i.e., one produced by the union of egg and sperm). The resulting embryo would have the same genetic material as that of the donor of the somatic cell nucleus, instead of its genome being the usual blend of two parents; thus this technique could allow potential parents to avoid passing on certain types of genetic conditions. Most commentators are opposed to human reproductive cloning, where the intention is to produce a cloned human embryo to implant in a woman in order to produce a pregnancy and eventually a child. As there are concerns about safety and long-term effects of cloning based on animal models, reproductive cloning is explicitly legally prohibited in several countries and is not known to be currently in clinical use.

Other ARTs

Additional types of ARTs have been developed in the last 20 years. Gametic intrafallopian transfer (GIFT) involves placement of eggs (which have been removed from the follicles) together with sperm directly into the oviducts for fertilization and is used with women with fallopian tube problems. After its development in the mid-1980s, this technique became very popular because it did not require sophisticated IVF culture systems and could be done in clinics with less ART expertise and without a full IVF laboratory. It also seemed to produce better results than IVF, perhaps because fertilization occurs in a natural environment; greater success rates also are due to the fact that patients are generally fertile except for blockage of the fallopian tubes. Zygote intrafallopian transfer (ZIFT) is a less common technique that involves transfer of the zygote (a fertilized egg that has not yet divided) into the oviduct after IVF. The ethical issues associated with GIFT and ZIFT are similar to those related to IVF-ET, although these procedures avoid the creation of embryos that might subsequently not be implanted.

Intracytoplasmic sperm injection (ICSI) is a micromanipulation technique in which pregnancy is achieved by injecting a single spermatozoon directly into the cytoplasm of the egg. It is used to enhance fertilization rates for men who have reduced sperm counts or impaired sperm motility, with banked sperm (obtained prior to chemotherapy or radiation), or with sperm obtained through electroejaculation (e.g., in those with spinal cord injuries or the newly dead, the latter being ethically and legally problematic). The technique also can be combined with those allowing separation of male and female sperm to avoid birth of children of a particular sex, for example to avoid sex-linked genetic disease or for sex selection, which is also ethically controversial. The practice of sex selection is outlawed in a number of countries because it is considered to be a morally problematic and discriminatory choice (or potentially because it results in gender imbalance in the broader population). It remains popular in cultures where having a child of a particular sex, or having a balanced family (i.e., some boys and some girls), is an important social norm.

Although ARTs have progressed rapidly over the past 30–40 years, there are still many limitations to their effectiveness. In addition, the ethical issues presented by ARTs remain controversial, particularly with regard to their potential impacts on women and their health, the appropriate use of selection criteria to determine who is eligible for treatment, and the disposition of excess embryos. In addition, there are specific public health implications that arise from the development of various ARTs outlined above. These include whether their use is appropriate in terms of resource allocation, especially since inability to reproduce might be viewed by many as less important than other, life-threatening health problems, and which selection criteria should be utilized, particularly given low success rates in some populations. In addition, concern exists about whether prevention of infertility, including identification and elimination of its causes, is being neglected, especially among certain minority populations, given the widespread availability of ARTs to the economically privileged. The dominant view that considers infertility as an individual problem, rather than as one which is associated with broader population-level social and medical issues, undoubtedly will continue to influence research and policy with regard to reproduction; however, it warrants more active and explicit debate.

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