ASSISTED REPRODUCTION TECHNOLOGY

On July 25, 1978, the work of Robert Edwards and Patrick Steptoe led to the birth of the first "test-tube baby," Louise Brown, in England. Since then, thousands of babies throughout the world have been born with the help of assisted reproduction technologies (ARTs). ARTs such as artificial insemination have been in use since the nineteenth century and, as with the technology that helped bring Louise Brown into existence, they still raise ethical concerns. Although ARTs are a common therapy to treat infertility, such treatments continue to provoke questions about safety and efficacy. Many of the ethical issues that appeared with the advent of these technologies continue to be relevant in the early twenty-first century.

Technologies

ARTs refer to a group of procedures, often used in combination, that are designed to establish a viable pregnancy for individuals diagnosed with infertility. The degree of sophistication of these techniques is highly variable. Artificial insemination (AI) requires the least technological complexity and is the oldest of such technologies. It consists of the mechanical introduction of sperm, from the husband or a donor, into a woman's reproductive tract. AI with the husband's sperm is indicated in cases where there are anatomical abnormalities of the penis, psychological or organic conditions that prevent normal erection and ejaculation, or female or male psychosexual problems that prevent normal intercourse. AI by donor is employed in cases of low sperm count or abnormal sperm function. It is also used by single women and by lesbian couples.

In vitro fertilization (IVF) is the quintessential type of ART. Approximately 1 million babies have been born worldwide through this procedure. In its most basic form (that is, the woman undergoing IVF provides her own eggs, and her husband or partner supplies the sperm), IVF consists of several stages. First doctors stimulate the woman's ovaries with different hormones to produce multiple oocytes. Next they remove the eggs from her ovaries through procedures such as laparoscopy or ultrasound-guided oocyte retrieval. After preparation of semen, specialists fertilize the mature eggs in a laboratory dish with the partner's sperm. If one or more normal looking embryos result, specialists place them (normally between three and five) in the woman's womb to enable implantation and possible pregnancy. The sperm and the eggs can also come from donors. Also the embryos might be cryo-preserved for later use and transferred into the woman who supplied the eggs or into a surrogate. Similarly examination of sperm, eggs, and embryos for chromosomal and genetic abnormalities can be performed through preimplantation diagnosis. Although IVF was originally developed to use in cases of infertility when the woman's fallopian tubes were damaged, it soon became common treatment for other reproductive problems such as inability to produce eggs, poor sperm quality, endometriosis, or unexplained infertility.

Several modifications and variations from the basic IVF procedure exist. In the gamete intrafallopian transfer (GIFT), the specialists transfer both eggs and sperm to the woman's tubes. Thus conception occurs inside the woman's body. With the zygote intrafallopian transfer (ZIFT), fertilization, as with IVF, occurs in a petri dish. The difference here is that the fertilized egg is transferred to the fallopian tube eighteen hours after fertilization occurs. The newest of these procedures is intracyto-plasmatic sperm injection (ICSI), which consists of the direct injection of one sperm into a harvested egg. Since the birth of Dolly the sheep in 1997, somatic cell nuclear transfer (SCNT) has been cited as another possible ART. In SCNT or reproductive cloning, the nucleus of a somatic cell is transferred into an egg cell from which the nucleus has been removed. Most countries have implemented bans or moratoriums on research directed to cloning human beings.

Although there are some ethical questions that are specific to particular reproductive technologies (for instance, manipulation of human embryos), many concerns are common to all. This entry will focus on ethical issues shared by all ARTs.

Procreation, Families, and Children's Well Being

Many of those who support the use and development of ARTs argue that people have a fundamental right to procreate. Thus the state should not interfere with the rights of infertile married couples to have offspring, unless compelling evidence of tangible harms is presented. Proponents claim that critics of ARTs have not offered such evidence (Robertson 1994). An emphasis on individual rights, however, might neglect the fact that reproduction is an act that clearly involves the community by bringing new persons into the world and by using societal resources.

From some religious perspectives, ARTs sever the natural link between sexual intercourse and procreation and, therefore, are impermissible. Many Christian theologians call the use of ARTs immoral because these technologies allow for the separation of procreation and sexual love between married partners (Ramsey 1970). Others contend that, within limits, ARTs can help infertile couples to reproduce and thus should not be completely rejected.

Some also argue that the use of ARTs challenges the traditional conception of the family by separating genetic, gestational, and rearing components of parenthood. Such criticisms assume that by family one can only mean a nuclear family composed of a male, a female, and their genetic offspring. They also ignore historical and anthropological evidence according to which humans have successfully adopted many kinds of family arrangements. Moreover such criticisms often fail to offer any compelling normative arguments that show that societies built of nuclear families, as generally understood, are better off than societies with other kinds of family arrangements (Coontz 1992).

The physical well being of children born through these technologies is another concern common to all the ARTs. Although initial assessments indicated that children born as a result of the use of ARTs did not suffer from more problems than did children born through conventional intercourse, such assessments are being questioned. Studies indicate that such children, especially those born through IVF and related techniques, are at increased risk of being premature, having low or extreme low birth weight, and suffering congenital malformations. It is still unclear, however, whether these risks are linked to the technologies themselves or to parental factors (Ludwig and Diedrich 2002).

Women's Well Being

Feminist criticisms have tended to focus on the effect of these technologies on the lives of women. They emphasize the risks that ARTs pose to women's health as well as their impacts on women's status in society. Some feminist groups argue that the new procedures are not designed to give women more choices but are based on the capitalist and patriarchal ideology of abusing, exploiting, and failing to respect women. They call attention to the dismemberment of women's bodies, the medicalization of the reproductive experience that puts pregnancy and birth in the hands of the medical profession, the commercialization of motherhood, and the eugenic and racist biases that the new technologies promote (Arditti et al. 1984.).

Other feminist authors have been less eager to completely reject ARTs. They maintain that assisted-conception techniques could be used to the advantage of women. Although they recognize that no technology is neutral, they reject the social and technological determinism that permeated initial feminist objections. These feminist critics acknowledge that the social policies surrounding ARTs harmed women's interests. However they oppose the image of women as brainwashed individuals, immersed in a world of constructed needs and unable to decide by themselves. They urge widespread public discussion and eventual political and legislative action to improve women's reproductive autonomy instead of a complete rejection of the new procedures (Callahan 1995).

Conception of Infertility

Another criticism common to all ARTs is that they reinforce a particular understanding of infertility as an individual medical failure to have children who are genetically related. Whether one views infertility mainly as a medical condition or also as a social one has important implications. Defining infertility as an individual medical difficulty suggests that a technological treatment is the appropriate response. Thus one might ignore that the causes of reproductive difficulties and the reasons that make infertility a serious concern are, in part, socially rooted. Analyzing infertility also as a socially generated problem indicates that social, ethical, and political solutions to reproductive difficulties should be considered. In this case there may be an emphasis on solutions such as preventive measures or social changes that might be more effective and less costly. This is especially noteworthy because sexual, contraceptive, and medical practices, occupational health hazards, environmental pollution, inadequate nutrition, and poor health are some of the main causes of infertility. Attention to these issues would require consideration of preventive measures rather than only curative treatments as solutions to the infertility problem.

Similarly the use of ARTs emphasizes the importance of genetic relationships in parenthood. One of the main goals of these technologies is to guarantee that at least one of the members of the couple would have genetically related offspring. Although a genetic link to one's offspring may be important, an emphasis on such a relationship might prevent social policies directed to facilitate and encourage adoption or other forms of parenting.

INMACULADA DE MELO-MARTÍN

SEE ALSO Bioethics;Feminist Ethics;In Vitro Fertilization and Genetic Screening;Medical Ethics;Rights and Reproduction.

BIBLIOGRAPHY

Arditti, Rita; Renate Duelli-Klein; and Shelley Minden, eds. (1984). Test-Tube Woman: What Future for Motherhood? London: Pandora Press. A collection of articles from a feminist perspective that address the ethical and medical implications of reproductive technologies for women's lives. Most of the authors are skeptical about the ability of these technologies to improve the lives of women.

Callahan, Joan. (1995). Reproduction, Ethics, and the Law: Feminist Perspectives. Bloomington: Indiana University Press. A collection of essays that consider moral and legal quandaries related to human reproduction. Without completely rejecting all ARTs, the authors call attention to new complexities brought about by these new technologies, such as the legal definition of parenthood, the status of frozen embryos, and the use of fetal tissue.

Coontz, Stephanie. (1992). The Way We Never Were: American Families and the Nostalgia Trap. New York: Basic Books. An analysis of some of the myths related to the so-called traditional two-parent nuclear family.

Ludwig, Michael, and Klaus Diedrich. (2002). "Follow-Up of Children Born after Assisted Reproductive Technologies." Reproductive Biomedicine Online 5(3): 317–322. Discusses the possibility that risks to the health of children born through ARTs might be related to the techniques themselves and not only to infertility related problems.

Ramsey, Paul. (1970). Fabricated Man: The Ethics of Genetic Control. New Haven, CT: Yale University Press. An evaluation of the implications of ARTs from a Christian perspective. The author rejects the use of these technologies for severing the sacred tie between procreation and married love.

Robertson, John. (1994). Children of Choice: Freedom and the New Reproductive Technologies. Princeton, NJ: Princeton University Press. A defense that the principle of procreative liberty should be used to resolve the ethical and legal controversies surrounding ARTs.