Current and future issues in assisted reproduction.

The last quarter of the twentieth century has given rise to reproductive technologies and arrangements that in the earlier part of the century could only be dreamed of by the authors of science fiction. We stand in the middle of this reproductive revolution, trying to cope with the developments that have already occurred but with an uneasy sense that the future may be even more complicated ethically than the past and the present. In this brief essay, I will survey recent ethical and public-policy discussions of two reproductive techniques (assisted insemination and in vitro fertilization) and one reproductive arrangement (surrogate motherhood). After distinguishing three phases in the normative debate, I will briefly comment on some of the characteristics of, and continuing ambiguities in, the ethical debate of the past 25 years. At the conclusion of the essay, I will attempt to anticipate three future issues in ethics and reproduction.     

Counselling needs of patients receiving treatment with gamete donation

Couples experiencing infertility may be offered treatment with gamete donation where other methods of treatment have failed or are inappropriate. This paper examines a range of concerns related to gamete donation. The paper does not attempt to present a comprehensive and critical review of the literature but concentrates on selecting from the literature, in addition to clinical material, issues which have been identified as contributing to an understanding of patients' experience of treatment with donated gametes. The concerns include feelings and attitudes towards the donor, the role the donor plays in the couple's relationship, feelings about not being the genetic parent and whether to disclose the donation to the potential child and others. These concerns form a basis for counselling couples about the implications of gamete donation for themselves and any children born as a result. The difficulties faced by some people are illustrated by consideration of a single case where the experience of donation linked up with unique aspects of that individual. Therapeutic counselling offers couples faced with such difficulties the opportunity to explore in a more extensive way the underlying dynamics of their concerns, enabling them to think about and make sense of their experience. © 1998 John Wiley & Sons, Ltd.     

Determining the status of non-transferred embryos in Ireland: a conspectus of case law and implications for clinical IVF practice

The development of in vitro fertilisation (IVF) as a treatment for human infertilty was among the most controversial medical achievements of the modern era. In Ireland, the fate and status of supranumary (non-transferred) embryos derived from IVF brings challenges both for clinical practice and public health policy because there is no judicial or legislative framework in place to address the medical, scientific, or ethical uncertainties. Complex legal issues exist regarding informed consent and ownership of embryos, particularly the use of non-transferred embryos if a couple separates or divorces. But since case law is only beginning to emerge from outside Ireland and because legislation on IVF and human embryo status is entirely absent here, this matter is poised to raise contractual, constitutional and property law issues at the highest level. Our analysis examines this medico-legal challenge in an Irish context, and summarises key decisions on this issue rendered from other jurisdictions. The contractual issues raised by the Roche case regarding informed consent and the implications the initial judgment may have for future disputes over embryos are also discussed. Our research also considers a putative Constitutional 'right to procreate' and the implications EU law may have for an Irish case concerning the fate of frozen embryos. Since current Medical Council guidelines are insufficient to ensure appropriate regulation of the advanced reproductive technologies in Ireland, the report of the Commission on Assisted Human Reproduction is most likely to influence embryo custody disputes. Public policy requires the establishment and implementation of a more comprehensive legislative framework within which assisted reproductive medical services are offered.     

REPRODUCTIVE TECHNOLOGY: A CRITICAL ANALYSIS OF THEOLOGICAL RESPONSES IN CHRISTIANITY AND ISLAM

Reproductive medical technology has revolutionized the natural order of human procreation. Accordingly, some have celebrated its advent as a new and liberating determinant of kinship at the global level and advocate it as a right to reproductive health while others have frowned upon it as a vehicle for “guiltless exchange of sexual fluid” and commodification of human gametes. Religious voices from both Christianity and Islam range from unthinking adoption to restrictive use. While utilizing this technology to enable the married couple to have children through the use of their own sexual material is welcome, the use of third party, surrogacy, and reproductive cloning are not in keeping with the sacrosanct principles of kinship, procreation through licit sexual intercourse, and social cohesiveness for building a cohesive family as uphold by both Christianity and Islam. To examine such larger issues emanating from these new ways of human procreation, beyond the question of legality, is a point which legal scholars in both Christianity and Islam, when issuing religious decrees, have not anticipated sufficiently. The article proposes to be an attempt to that end through a qualitative critical content analysis of selected literature written on the subject.     

Counseling and screening for cystic fibrosis in patients with congenital bilateral absence of the vas deferens: Patient perceptions

Congenital bilateral absence of the vas deferens (CBAVD) occurs in approximately 1.3% of infertile males and is thought to be, in most cases, a primarily genital form of cystic fibrosis (CF). Fourteen males with CBAVD considering microsurgical sperm aspiration from the epididymis (MESA) and in vitro fertilization were seen for genetic counseling and screening for CF. To retrospectively evaluate these patients' perceptions of the counseling and screening information, we conducted structured telephone interviews to assess their recall of information about CF and its impact on their health concerns and reproductive plans. We found that, as the health implications of CF are abstract and not as important to patients as the diagnosis of CBAVD itself, patients tend to view their CF status primarily in terms of their reproductive potential. Retrospective analysis afforded us an opportunity to identify the psychosocial issues of most concern to this unique patient population.     

Depression, SSRIs, and the supposed obligation to suffer mentally

Within both popular and academic literature, concerns have been expressed about the implications of antidepressant use on character development. In this paper, I identify specific versions of these worries and argue that they are misguided. I begin by arguing that the obligation to suffer if it will bring about a noble character is imagined. Legitimate concerns about character enhancement remain, but they do not count against most antidepressant use. Thus there is no moral prohibition against antidepressant use. Furthermore, some of the calls for caution about antidepressant use, such as those expressed by the President's Council on Bioethics, are overstated.     

Overview: Sex Roles, Fertility and the Motherhood Mandate

Abstract: The centrality of motherhood to woman's identity is characterized as a mandate that is built into our social institutions as well as our psyches. This mandate is reflected in the assumptions of the models and methods of research in the psychology of women. An examination of the impact of the motherhood mandate is encouraged and complexities that must be reflected in research models and methods are underscored. These complexities include the need for (1) appreciation of the context of the phenomena studied; (2) interactionist approaches, including multivariate models and methods; and (3) a multidisciplinary perspective, including biological, psychological, social and structural levels of analysis. Two facets of the changing context having profound implications for the meaning of motherhood are reproductive freedom and voluntary childlessness.     

Is Teenage Sexual Behavior Rational?1

We evaluate the applicability of a decision making framework to the teenage contraceptive and sexual behavior of 1032 Philadelphia teenagers. We examine three reasons why the decision making perspective may not apply in this domain: (a) because the decision makers are teenagers, (b) because the decision concerns sexual behavior, and (c) because the costs of contraception and abstinence are immediate and certain, while the benefits are delayed and uncertain. Using multiple regression, we examine the predictors of sexual activity and contraceptive use. We find support for the decision making model in that the variables ordinarily included in decision analyses do significantly predict behavior. But respondents seem to place disproportionate weight on some considerations, such as the discomfort of using birth control, and very little on others, such as the effectiveness of birth control or their attitude toward motherhood.     

Exclusion and Essentialism in Feminist Theory: The Problem of Mothering

Accounts of mothering have both contributed to feminist theory's development and depended on certain of its central concepts. Some of its critics, however, argue that feminist theory is undermined by the problems of exclusion and essentialism. Here I distinguish between these two problems and consider their implications for questions about mothering. I conclude that exclusion and essentialism do not present insurmountable obstacles to theorizing motherhood, but do suggest new directions for such theorizing.     

Cutting Motherhood in Two: Some Suspicions Concerning Surrogacy

Surrogate motherhood—at least if carefully structured to protect the interests of the women involved—seems defensible along standard liberal lines which place great stress on free agreements as moral bedrocks. But feminist theories have tended to be suspicious about the importance assigned to this notion by mainstream ethics, and in this paper, we develop implications of those suspicions for surrogacy. We argue that the practice is inconsistent with duties parents owe to children and that it compromises the freedom of surrogates to perform their share of those duties. Standard liberal perspectives tend to be insensitive to such considerations; we propose a view which takes more seriously the moral importance of the causal relationship between parents and children, and which therefore illuminates rather than obscures the stake that women and children have in surrogacy.     

Childless

This paper explores the complex interplay that unfolded between analyst and patient around their respective childlessness and aims to draw attention to the larger societal issues of imperative parenthood and the stigma of childlessness. As the analyst confronted her own internal conflicts about motherhood, children, and procreation as a woman living in a pronatalist society (one that encourages increasing birth-rates), she was treating a lesbian patient with a history of childhood relational trauma and sexual abuse who was undergoing fertility treatments. The patient’s experience with assisted reproductive technologies raised complicated questions and concerns within the analyst regarding their emotional impact on her patient and, more broadly, how they might reflect societal dissociation. Themes of trauma, loss, dissociation, and shifting self-states, which emerged during the fertility treatments and wove their way throughout the analysis, are discussed. In addition, the author describes the nature of the therapeutic action in this case.     

Waiting to be born: the ethical implications of the generation of "NUBorn" and "NUAge" mice from pre-pubertal ovarian tissue

Oncofertility is one of the 9 NIH Roadmap Initiatives, federal grants intended to explore previously intractable questions, and it describes a new field that exists in the liminal space between cancer treatment and its sequelae, IVF clinics and their yearning, and basic research in cell growth, biomaterials, and reproductive science and its tempting promises. Cancer diagnoses, which were once thought universally fatal, now often entail management of a chronic disease. Yet the therapies are rigorous, must start immediately, and in many cases result in premature failure of the body's reproductive ability. In women, this loss is especially poignant; unlike the routine storage of sperm, which is done in men and boys facing similar treatment decisions, freezing oocytes in anticipation of fertility loss is not possible in most cases, and creating an embryo within days of diagnosis raises significant moral, social and medical challenges. Oncofertility is the study of how to harvest ovarian tissue in women facing cancer to preserve their gametes for future use with IVF, thus allowing the decisions about childbearing to be deferred and reproductive choices to be preserved. The research endeavor uses the capacity of the ovarian follicle to produce eggs in vitro. Developing the human follicle to ovulate successfully outside the body is scientifically difficult and ethically challenging. Infertility is linked to long-standing religious and moral traditions, and is intertwined with deeply contentious social narratives about women, families, illness and birth. Is the research morally permissible? Perhaps imperative if understood as a repair from iatrogenic harms? How are considerations of justice central to the work? How will vulnerable subjects be protected? What are the moral implications of the work for women, children and families? What are the implications for society if women could store ovarian tissue as a way of stopping the biological clock? What are the moral possibilities and challenges if eggs can be produced in large quantities from a stored ovarian tissue?     

When Daughter Becomes Mother: Inferences from Multiple Dyadic Parent–Child Groups

In this paper, I describe how new mothers can be preoccupied with their mothers and can replay their relationship with them transferentially with professionals and nannies, who become surrogates for their mothers. New mothers need affirmation from their mothers and from mother surrogates because, in their new role, they experience a sense of helplessness and anxiety and have difficulty tolerating aggression, ambivalence, and conflict. Stern's “motherhood constellation” and “good grandmother transference” are useful constructs for understanding how to best approach and help new mothers and their babies. From observations in multiple dyadic parent–child groups at the Pacella Parent Child Center, I have distilled two factors that help new mothers address their anxieties—the bonds these mothers make with one another and their transferential bond with the group leader and other professionals at the center. I critically discuss and compare theoretical inferences derived from individual psychoanalytic or psychotherapeutic work (as exemplified by Balsam's work) with the inferences derived from Stern's dyadic model and with inferences derived from psychoanalytically informed group situations. I consider the implications of the ubiquity of ambivalence conflicts, especially around aggression.     

Work Place Flexibility: Implications for Developmental Opportunities and Work-Family Conflicts

Contemporary HR practices in the business organizations today have moot concerns towards managing workplace in such a way that it is desirable for both employees and employers. This study proposes to assess the consequences of workplace arrangement promoting the individualization of employment conditions, i.e. flexible working hours- part time work and telecommuting. The implications of flexible working hours on the development opportunities available to employees and on work-family conflict are suggested. It is argued that flexibility at work place in terms of part time work and telecommuting options have the potential to reduce work-family conflict and reduced development opportunities among employees. It is concluded that work life balance depends on the fit between the schedule that employee needs and the actual number of hours worked. To this end effective use of flexible hours at work place needs to be identified and implemented.     

The psychological impact of reproductive difficulties on women's lives

Little is known about the long-term impact of reproductive experiences on women's lives. This paper uses questionnaire data collected from 107 White female college graduates, when they were approximately 47 years old. More than half the sample had experienced at least one type of reproductive difficulty (abortion, miscarriage, or infertility). The stress and coping model of life difficulties (Lazarus and Folkman, 1984) was used to examine the relationship between the women's reproductive difficulties and emotional sequelae, politicization, and orientation to motherhood at midlife. As predicted, emotional responses to the reproductive difficulties varied according to the particular nature of each experience. In addition, women who had abortions and no other difficulties were more politicized at midlife than other women. Women whose reproductive experiences were especially likely to arouse feelings of not being in control of their life (those who had miscarriages or infertility) described a more agentic orientation to motherhood when compared with other women.     

Selling Babies and Selling Bodies

I will argue the free market in babies or in women's bodies created by an institution of paid surrogate motherhood is contrary to Kantian principles of person-hood and to the feminist principle that men do not have—and cannot gain through contract, marriage, or payment of money—a right to the sexual or reproductive use of women's bodies.     

Patterns of Mother-Infant Contact: The Significance of Lateral Preference

The use of assisted reproductive technology is increasing rapidly. Research, although sparse, has resulted in inconsistent findings as to the developmental prognosis for infants conceived by assisted reproductive techniques such as in vitro fertilization and the use of fertility drugs. In the present study, the authors compared twins who were spontaneously conceived with those who were conceived through assisted reproductive technology. The authors found differences in birth weight and gestational age. Infants conceived by assisted reproductive technology fared worse than did those who were spontaneously conceived. The authors found no differences between the groups in mental development at 24 months of age, but they found evidence of differences in physical development. Implications of the findings are discussed.     

Assisted reproduction versus spontaneous conception: a comparison of the developmental outcomes in twins

The use of assisted reproductive technology is increasing rapidly. Research, although sparse, has resulted in inconsistent findings as to the developmental prognosis for infants conceived by assisted reproductive techniques such as in vitro fertilization and the use of fertility drugs. In the present study, the authors compared twins who were spontaneously conceived with those who were conceived through assisted reproductive technology. The authors found differences in birth weight and gestational age. Infants conceived by assisted reproductive technology fared worse than did those who were spontaneously conceived. The authors found no differences between the groups in mental development at 24 months of age, but they found evidence of differences in physical development. Implications of the findings are discussed.     

Consequences of teenage pregnancy and motherhood

In the past 15-20 years there has been a significant increase in sexual activity among teenagers as well as an increase in the rate of pregnancy. Teenage pregnancy has many social, psychological, economic and health consequences. Although there has been a significant increase in the use of abortion since the early 1970s among white teenagers, the majority of pregnant teenagers opt to carry their pregnancy to term and raise their child themselves. This review of the literature concerns itself with some of the variables associated with adolescent sexual behavior focusing on teenage pregnancy and the consequences of motherhood on child development. Suggestions are made for strategies that may be effective in ameliorating some of the problems as well as the research required for evaluating such strategies.     

Reproductive justice for incarcerated mothers and advocacy for their infants and young children

The United States has seen unprecedented growth in the number of incarcerated women, most of whom are mothers with minor children. Major public health concerns relate to the reproductive health of women in prisons and jails and the well-being of their infants and young children. In the current article, we use a reproductive justice framework to examine the intersection of incarceration and maternal and child health. We review (a) current research on the reproductive health of incarcerated women, (b) characteristics and experiences of pregnant incarcerated women, (c) outcomes of infants and young children with incarcerated parents, (d) implications of research findings for policy and practice, and (e) the need for increased research, public education, and advocacy. We strongly recommend that correctional policies and practices be updated to address the common misconceptions and biases as well as the unique vulnerabilities and health needs of incarcerated women and their young children.