SINCE THE BIRTH OF THE FIRST CHILD CONCEIVED BY IN vitro fertilization more than 20 years ago, the applications of assisted reproduction have expanded rapidly. A single sperm can be injected directly into a single ovum to overcome severe male-factor infertility. An ovum from a young donor can be fertilized and implanted in a postmenopausal woman so she can carry the fetus. In vitro fertilization, in combination with DNA or karyotype analysis of a single cell from the developing embryo (preimplantation diagnosis), allows implantation of embryos that are free of genetic defects in couples without infertility. At every new step along the evolving pathway of assisted reproduction, ethical concerns have been raised. However, thus far, the techniques have been permitted—in part because of a widespread but tacit assumption that promotion of reproductive freedom, or in today’s language, reproductive autonomy—is an unqualified interest or good. But is reproductive freedom an unqualified good to society, the individuals undergoing the procedure, the medical profession, the businesses sponsoring such technologies, or the offspring thus produced? Reproductive freedom is such a widely accepted norm in Western society that some even assume it to be an individual’s absolute or inalienable right. But experience teaches that, like interests and goods, rights cannot be absolutely unqualified. First, there will always be disagreements about what these rights are, who grants them, and the source of their legitimacy. Even if everyone could agree on what they were, more than one right, interest, or good exists, guaranteeing that conflicting claims will occur and, if those conflicts are to be resolved, some negotiation will be necessary. Moreover, rights necessarily entail responsibilities, which also include respecting the rights of others and often qualify or even directly conflict with an individual’s rights. Thus, reproductive freedom, like other such ideas, is an ideal to work toward, and not a guaranteed right. In any issue that deals with a right, good, or responsibility, it is imperative that all of the values of all relevantly affected individuals be represented, articulated, and discussed. Otherwise, rights are merely being used like bludgeons or, as Churchill and Siman call them, trump cards: whoever has the biggest stick or holds the trump card wins, and everyone else loses. Most such conflicts are not zero-sum games but are complicated balancing acts in which multiple competing claims need to be adjudicated so that risk to those most vulnerable or relevantly affected is minimized. But this only reflects that which is most characteristic of an ethical problem, ie, there is usually no good solution but a range of less than optimal choices, one of which must be chosen— since even not choosing is a choice by default. The American Society for Reproductive Medicine Ethics Committee, anticipating such difficulties, has published reports to provide some guidance in some of these areas of concern. For instance, there is support for sex selection in preimplantation diagnosis when there is a medical indication such as Duchenne muscular dystrophy. For some women, it is more acceptable to refrain from reimplanting affected embryos than to terminate a fetus diagnosed with a genetic disease. However, in current culture, sex selection is, under ordinary circumstances, to be discouraged. Moreover, no physician is legally or ethically bound to provide preimplantation sex selection services when requested by a fertile couple without a compelling medical (genetic) reason. In the interest of both the mother’s and the child’s optimal welfare, an upper age limit of 55 years for postmenopausal donor egg recipients has been proposed. Thus, while compelling reasons must be provided to justify limiting reproductive freedom—such as the likelihood of serious harmful consequences or the existence of a stronger competing value—a wide range of possibilities for assisted reproduction remains. The study by Verlinsky and colleagues in this issue of THE JOURNAL brings renewed concern to the issue of what does, or should, constitute ethically acceptable assisted reproduction. The authors have provided a woman with the oppor-
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Mar 13, 2022
Martin Kolk + 1
Open Access
