VIII. ETHICAL ISSUES

The introduction of in vitro fertilization (IVF) in 1978 sparked anew an intense ethical debate about the use of innovative reproductive technologies that had raged a decade earlier. Questions were raised about whether these technologies would harm children and parents and alter people's understanding of the meaning of procreation, family, and parenthood. Gradually the controversy subsided as healthy children were born from these procedures; committees in at least eight countries issued statements indicating that they considered the use of IVF ethically acceptable in principle (Walters). Arguably, one reason for this readiness to embrace IVF and other new reproductive techniques was that they enabled couples to create offspring in a way that seemed an extension of the natural way of procreating. Although IVF involved joining sperm and ovum in a glass dish, the resulting embryo, once implanted, went through a natural period of gestation that culminated in the birth of a child. A second reason was that these technologies, with the exception of artificial insemination by donor, allowed people to have children who were genetically their own. Louise Brown, the first child created through IVF, resulted from the union of the gametes of her biological parents. Third, the children born of these new means of reproduction were born into traditionally structured families. These techniques were assumed to have been developed for use by married couples who, with the new baby, would form what was ordinarily defined as a nuclear family.

In the 1990s, these rationales for accepting novel reproductive technologies are being challenged by medical advances and a changing social environment. Human intervention in the procreative process has become more frequent, more complex, and more highly technological. Oocytes can be removed surgically from one woman and, after fertilization, transferred to another in the procedure of oocyte donation. Women can lend their wombs to others for the incubation of children who have no genetic connection to such "surrogates." Embryos created in vitro can be cryopreserved and stored for use in future years by their genetic parents or by others. Consequently, it is difficult to argue that such innovative measures are mere extensions of the natural way of reproducing. Parthenogenesis (stimulating an unfertilized egg to develop and produce offspring by mechanical or chemical means), cloning (deriving genetically identical organisms from a single cell or very early embryo), and ectogenesis (maintaining the fetus completely outside the body) are on the horizon. Furthermore, third, fourth, and fifth parties, such as oocyte donors, surrogate mothers, and (some suggest) even fetuses and cadavers, are joining sperm donors to assist those who are childless to have offspring. New forms of assisted reproduction are increasingly being used to create children who are not tied to those who will raise them by biological or hereditary links. Finally, these technologies are no longer used almost exclusively to create traditional nuclear families. Unmarried heterosexual and homosexual couples and single women and men now have greater access to them. Such scientific and social changes give new emphasis to the older unresolved ethical questions about the uses of these technologies and raise new questions. Ethical questions raised by the use of the new reproductive technologies The initial ethical question created by these technologies is whether they ought to be used at all. Different religious traditions vary tremendously in their judgments about the licitness of the use of these novel techniques. The Roman Catholic church declared the use of new reproductive technologies morally unacceptable (Catholic Church) because they separate the procreative, life-giving aspects of human intercourse from the unitive, lovemaking aspects, and these, according to Catholic teachings, are morally inseparable in every sexual act. The creation of a child should involve the convergence of the spiritual and physical love of the parents; fertilization outside the body is "deprived of the meanings and the values which are expressed in the language of the body and in the union of human persons" (Catholic Church, p. 28).

Certain other religious groups, such as the Lutheran, Anglican, Jewish, Eastern Orthodox, and Islamic, view some of these methods as ethically acceptable because God has encouraged human procreation (Lutheran Church; Episcopal Church; Feldman; Harakas; Rahman). According to these bodies, it is sufficient that love and procreation are held together within the whole marital relationship; each act of sexual intercourse need not be open to the possibility of conception. Still other religious groups hold that there is no necessary moral connection between conjugal sexual inter-course and openness to procreation, and consequently they accept the use of the new reproductive technologies with few qualifications (Smith; Simmons; General Conference). In Hindu thought, for instance, although there is no authoritative teaching on this subject, the mythologies of ancestors appear to allow IVF, oocyte donation, embryo implantation, and surrogacy (Desai).

Feminists, too, are split about the use of the new reproductive technologies. Some argue that these novel methods define and limit women in ways that demean them, for example, as "fetal containers." They maintain that the desire of many women, both fertile and infertile, for children is, in large part, socially constructed (Bartholet, 1992; Williams). The cultural imperative to have children drives infertile women to undergo physically, emotionally, and financially costly treatment. They are thrust into the hands of a predominantly male medical establishment that uses women as "living laboratories" whose body parts they manipulate without regard to the consequences (Rowland). Male experts sever what was once a continuous process of gestation and childbirth for women into discrete parts, thereby fragmenting motherhood (Corea).

In contrast, other feminists argue that the new reproductive technologies enhance the status of women by providing them with an increased range of options. By circumventing infertility and providing women with alternative means of reproducing, these technologies extend reproductive choices and freedoms (Jaggar; Andrews; Macklin, 1994). In their view, the charge that surrogacy exploits women is paternalistic because it questions women's ability to know their own interests and to make informed, voluntary, and competent decisions (Macklin, 1990); women have the ability and right to control their bodies and to make autonomous choices about their participation in such practices, these feminists argue.

Some people recommend adoption over the use of the new reproductive technologies because they view the latter as physically and emotionally debilitating and unlikely to succeed, whereas adoption, while not easy, provides a home and family for children in need (Bartholet, 1993). Yet adoption is a second choice for many infertile couples because of its perceived drawbacks. These include the declining number of healthy children available for adoption, the long and emotionally draining wait, the expense, and the difficult and often frustrating system with which adoptive parents must deal (Lauritzen). Although the use of assisted reproduction presents some of the same problems as adoption, it offers what some infertile couples consider distinct advantages: It allows them to have children who are genetically related to at least one of them and (except in the case of surrogacy) makes the experience of pregnancy and birth available to the woman. The desire to reproduce through lines of kinship and to connect to future generations exerts a powerful influence, as does the hope of experiencing the range of fulfilling events associated with pregnancy and childbirth (Overall).

Individual Choice, Substantial Harm, and Community Values

A central issue in the debate about the use of reproductive technologies concerns the scope that should be given to individual discretion over their use. Some philosophical commentators, emphasizing personal autonomy, enunciate a broad moral right to reproduce by means of these technologies (Bayles; Brock). They borrow from legal discussions of the right to reproduce, which some legal theorists take to include the liberty to use methods of assisted reproduction (Robertson, 1986; Elias and Annas, 1987). To limit individual choice about noncoital means of reproduction, the state must show that the use of specific reproductive technologies threatens substantial harm to participants and the children born to them (Robertson, 1988). The philosophers influenced by such legal positions maintain that individuals have great leeway in their choice of whether to procreate, with whom, and by what means. They have a right to enter into contractual arrangements giving them access to these technologies and to utilize third parties in their reproductive efforts. Those who take this approach concede that substantial adverse effects on others, particularly the children, would justify restricting individual use of assisted reproduction.

Since the primary reason for accepting these innovative methods is to bring children into the world, a major consideration in assessing them is whether or not they harm these children. Critics contend that these techniques may cause social and psychological problems to the resulting children because of confusion they engender over divided biological parentage and the social stigmatization to which they may be subjected (Callahan, 1988). John Robertson responds that this criticism is logically incoherent. When the alternative is nonexistence, he argues, it is better for the children to have been born—even though they may experience some harm from the means used to bring them into the world—than never to have existed at all (Robertson, 1986). In most cases, the difficulties they face are not so great as to render life a complete loss.

There are several problems with this influential response. One is that it justifies allowing almost any harm to occur to children born as a result of the use of these techniques in that it can almost always be said they are better off alive. Moreover, this argument presupposes that these children are waiting in a world of nonexistence to be summoned into existence and that they would be harmed by not being born. Since children do not exist at all prior to their arrival in this world, there are no children who could be harmed by not being born. When we say that it is better for a child to have been born, we do not compare that child's current existence with a previous one. Instead, we make an after-the-fact judgment that life is a good for an already existing child, even though that child may have suffered some harm from the technology used to bring him or her into the world. Critics of the use of the new reproductive technologies, however, make a before-the-fact judgment about children who do not exist, but who might. They maintain that it would be wrong to bring children into the world if they would suffer certain substantial harms as a result of the methods by which they are created. This is a logically coherent claim that justifies considering whether the new reproductive technologies severely damage children born as a result of their use.

The criterion of avoiding substantial harm, while valid, may provide inadequate ethical constraints on various ways of employing the new reproductive arrangements. The criterion is derived from a position that especially prizes individuality, liberty, and autonomy—quite possibly at the cost of values that are served by the building of families and communities, and by accounting for the common good (Cahill). Taking respect for individual freedom as the primary value, according to Allen Verhey, runs the danger of reducing the value of persons to their capacities for rational choice and denying the significance of the communities that shape them. People are not just autonomous individuals, they are also members of communities, some of which are not of their own choosing. Freedom is insufficient for an account of the good life in the family. Thus, it may be morally legitimate to recommend limits to individual choice about assisted reproductive techniques, not only to protect the children born of these methods but also to uphold basic community values. What is at issue, he suggests, is what kind of society we are and want to become (Verhey).

Ethical Issues Related to the Introduction of Third Parties

The introduction of third parties into procreative acts, according to some critics, imperils the very character of society by threatening the nuclear family, the basic building block of U.S. society (Callahan, 1988). Religious commentators and groups, in particular, have expressed concern about the effect of the use of gamete donors and surrogates on the relation between married couples within the nuclear family. Richard McCormick, a Roman Catholic theologian, argues that when procreation takes place in a context other than marriage (as when single women use artificial insemination by donor, for example) and another's body is used to achieve conception (as in the case of surrogacy, for example), total dedication to one's spouse is made more difficult; in Roman Catholic terminology, it also violates "the marriage covenant wherein exclusive, nontransferable, inalienable rights to each other's person and generative acts are exchanged" (Ethics Committee, 1986, p. 82).

In Islamic law, artificial insemination by donor is rejected on grounds that the use of the sperm of a man other than the marriage partner confuses lineage and might also constitute a form of adultery because a third party enters into the procreative aspect of the marital relation. The practice is highly controversial in the Jewish religion because (1) some consider it a form of adultery; (2) some take the resulting child to be illegitimate; and (3) if the donor is unknown, the practice might eventually result in incestuous marriage between siblings. Most other religious groups that have commented on surrogacy also reject it because it depersonalizes motherhood and risks subjecting surrogates and procreation itself to commercial exploitation. Such practices will lead people to regard children as products who, in Oliver O'Donovan's terms, are "made" rather than "begotten."

Those who wish to counter concerns about adultery distinguish between adultery and the use of a gamete or womb contributed by a third party to assist a married couple to have a child. A necessary element of adultery, they contend, is sexual intercourse; neither gamete donation nor surrogacy involves sexual contact between the recipient and the donor. Moreover, unlike adultery, no element of unfaithfulness need inhere in participation in gamete donation. Indeed, a couple may participate in gamete donation just because they have a strong commitment to their marriage, rather than out of disdain for it (Lauritzen). When only one parent can contribute genetically to the procreation of a child, but both can nourish and nurture a child, this argument runs, it is ethically acceptable for them to have a child by means of third-party collaboration.

The use of third parties in the provision of the new reproductive technologies leads to confused notions of parentage, critics note, since it severs the connection between the conceptive, gestational, and rearing components of parenthood. It can be difficult to predict who will be declared the rearing parent in different reproductive scenarios, despite the fact that they embrace the same set of facts. For instance, in IVF followed by embryo transfer, the woman who gestates an embryo provided by someone else is considered the mother of the resulting child, but in artificial insemination by donor she is not. Those who respond to this criticism, in attempting to develop a consistent ethical basis for awarding the accolade of parenthood, give priority either to the interests of the children born of these technologies or to those of their adult progenitors.

Those who view the interests of the children as of prime importance argue that genetic connections should constrain the freedom to choose parental status in that biological kinship relations are important to children's development and self-identity (Callahan, 1988). Purposefully to break the link between procreation and rearing, these commentators maintain, harms children born of these procedures because it obscures their identity within a family lineage. Indeed, it has been argued that the biological relationship between gamete donors and the children who result from their contributions carries an obligation for donors to support and nurture those children (Callahan, 1992). Respondents observe that it is not considered wrong to separate the genetic and rearing components of parenthood in such well-established arrangements as adoption, stepparenting, blended families, and extended kin relationships. This precedent suggests that, although the genetic relation may be important, it is not essential to parenthood.

Caring for and raising a child are of greater significance for parenthood than providing the genetic material or gestational environment, according to this view. Consequently, the rearing parent should have moral priority over the genetic parent in the interests of the child (Lauritzen). Others focus on the interests of the parents when the choice is between the genetic and the gestational mother, and they contend that the gestational mother should prevail because of her greater physical and emotional contribution and the risks of childbearing (Elias and Annas, 1986).

Parents who are not the biological progenitors of the children they raise and those who provide them with gametes often fear social stigmatization. This raises the question of whether anonymity and secrecy should be used to envelop all who participate in the use of the new reproductive technologies for their own protection. Anonymity has to do with concealing the identity of the donor; secrecy has to do with concealing the fact that recipients have participated in gamete donation. The practice of artificial insemination by donor has historically been carried out in secrecy with anonymous donors to protect family and donor privacy; oocyte donation, which began with openness about the identity of donors, is moving in that direction as well. The major argument against this development takes the interests of the children as primary and contends that since the personal and social identity of children is dependent on their biological origins, they ought to know about their genetic parents (National Bioethics Consultative Committee). Several countries that accept this argument have adopted regulations allowing children, when they reach maturity, to gain access to whatever information is available about donors who contributed to their birth.

Technologies of assisted reproduction, especially those involving third parties, facilitate the creation of models of family that depart significantly from the traditional nuclear family. As single persons, homosexual couples, and unmarried heterosexual couples increasingly gain access to these technologies, both religious and secular bodies express concern about weakening mutual commitment within the family and about the welfare of the resulting children. Sherman Elias and George Annas observe that "it seems disingenuous to argue on the one hand that the primary justification for noncoital reproduction is the anguish an infertile married couple suffers because of the inability to have a 'traditional family,' and then use the breakup of the traditional family unit itself as the primary justification for unmarried individuals to have access to these techniques" (1986, p. 67). The Warnock Report, developed by a commission of inquiry into the use of artificial means of reproduction in Great Britain in 1984, concluded that "the interests of the child dictate that it should be born into a home where there is a loving, stable, heterosexual relationship and that, therefore, the deliberate creation of a child for a woman who is not a partner in such a relationship is morally wrong" (p. 11).

Some psychologists claim that children who grow up in these nontraditional families will suffer psychological and social damage because they will lack role models of both genders and may consequently develop an impaired view of sexuality and procreation (McGuire and Alexander). Moreover, they argue, two parents are better able than one to cope with the demands of childrearing. Other studies have been used to vindicate the opposite conclusions (McGuire and Alexander). Since few studies have been carried out on the consequences for children of atypical family arrangements that emerge when the new reproductive technologies are employed, it is difficult to provide any clear evidence to support or undermine these opposing contentions. A further concern voiced is that using new reproductive technologies to assist single people and homosexual couples to have children involves a misuse of medical capabilities because these methods are not being employed to overcome a medical problem but to circumvent biological limits to parenthood.

To others, however, the use of new methods of assisted reproduction by single people and homosexual couples mirrors the reality that U.S. society has begun to move away from the nuclear family (Glover). They see the inclusion of homosexual parents within the meaning of family as a move toward greater equality in a society in which those who are homosexual suffer from prejudice and discrimination. If single people and homosexual couples can offer to a child an environment that is compatible with a good start in life, the Glover Report to the European Commission maintains, they ought to have access to these techniques, but it is appropriate for those providing them to make some inquiries before proceeding (Glover). The Royal Commission on New Reproductive Technologies of Canada approved of allowing infertility clinics to provide single heterosexual and lesbian women access to donor insemination on grounds that no reliable evidence could be found that the environment in families formed by these gamete recipients is any better or any worse for the children than in families formed by heterosexual couples (Canada, Royal Commission on New Reproductive Technologies).

Ethical Issues Related to Commodification

A concern of special ethical significance is that the introduction of third parties into some of the new reproductive techniques carries with it the danger of commodification of human beings, their bodies, and their bodily products. Giving payment of any sort to surrogates and gamete donors, some argue, risks making them and the children produced with their assistance fungible objects of market exchange, alienating them from their personhood in a way that diminishes the value of human beings (Radin). Third parties who assist others to reproduce should be viewed as donors of a priceless gift for which they ought to be repaid in gratitude, but not in money.

Others argue that persons have a right to do what they choose with their bodies and that when they choose to be paid, their reimbursement should be commensurate with their services (Robertson, 1988). The value of respect for persons is not diminished by using surrogates and gamete donors for the reproductive purposes of others if those third parties are fully informed about the procedure in which they participate and are not coerced into participating—even when they are paid (Harris). There is a presumption on all sides that third parties should not be specifically compensated for their gametes, wombs, or babies. Several groups that have considered the matter, though, such as the Warnock Committee in Great Britain (Warnock) and the Waller Committee in Australia (Victoria), allow third-party payment for out-of-pocket and medical expenses. The American Fertility Society goes further when it maintains that gamete donors should be paid for their direct and indirect expenses, inconvenience, time, risk, and discomfort (Ethics Committee, 1990). It would be unfair and exploitive not to pay donors for their time and effort, John Robertson argues (1988).

Offering large amounts of money to third parties incommensurate with the degree of effort and service that these persons provide may diminish the voluntariness of their choice to participate in assisted reproduction, particularly when they have limited financial means. There is concern that a new economic underclass might develop that would earn its living by providing body parts and products for the reproductive purposes of those who are better off economically. This would violate the principle of distributive justice, which requires that society's benefits and burdens be parceled out equitably among different groups (Macklin, 1994). However, if poor women and men have voluntarily and knowingly accepted their role in these reproductive projects, it could be seen as unjustifiably paternalistic to deny them the opportunity to earn money. The possibility of exploitation of the poor must be weighed "against a possible step toward their liberation through economic gain" from a new source of income connected to innovative methods of reproduction (Radin).

Ethical Issues Related to the Uses of Embryos, Fetuses, and Cadavers

When the process of fertilization is external, the embryo becomes accessible to many forms of intervention. During the brief extracorporeal, in vitro period, embryos can be frozen, treated, implanted, experimented on, discarded, or donated. Theoretically, embryos that result from IVF could be cryopreserved for generations, so that a woman could give birth to her genetic uncle, siblings could be born to different sets of parents, or one sibling could be born to another. A 1993 experiment in which human embryos were split reawakened concerns about these sorts of possibilities, which had remained dormant since a mid-1970s controversy about cloning human beings (National Advisory Board). (Cloning, either by transplanting the nucleus from a differentiated cell into an unfertilized egg from which the nucleus has been removed or by splitting an embryo at an early stage when its cells are still undifferentiated, results in individuals who are genetically identical to the original from which they are cloned.)

Advocates of embryo splitting view it as a way of obtaining greater numbers of embryos for implantation in order to enhance the chances of pregnancy for those who are infertile (Robertson, 1994). Critics claim that cloning in any form negates what we view as valuable about human beings, their individuality and uniqueness. It risks treating children as fungible products to be manipulated at will, rather than as unique, self-determining individuals. These critics maintain that twinning that occurs in nature is an unavoidable accident that does not involve manipulation of one child-tobe to produce a duplicate (McCormick, 1994). Defenders of cloning respond that the similarity of identical twins does not diminish their uniqueness or their sense of selfhood. In any case, cloned individuals would not be identical in that the genome does not fully determine a person's identity. Environmental factors, such as family upbringing and the historical context, weigh heavily in influencing the expression of genes (National Advisory Board).

It is the potential for abuse of cloning that disturbs most critics. The possibility of cryopreserving cloned embryos suggests the option of implanting cloned embryos and bringing them to term should their already-born twin need a tissue or organ transplant. In another scenario, embryos derived from parents who are likely to produce "ideal specimens" would be cloned and sold on a "black market." Critics condemn such potential applications of cloning because they diminish the value of embryos and of human beings by treating them as objects available for any use by others (National Advisory Board). They are concerned that the deep desire of the infertile for children, in combination with scientific zeal and market forces, will create strong pressure to clone embryos without a view to the ethical considerations involved. In 1993 scientists in the United Kingdom announced the possibility of using for infertility treatment eggs and ovaries taken from aborted fetuses (Carroll and Gosden). The eggs could be fertilized in vitro and then transferred into infertile women who lack viable eggs; the ovaries could be transplanted directly into women to mature and produce eggs.

This would help meet the shortage of oocytes for those who lack their own. Such uses of aborted fetuses, however, are highly contentious and strike some as grotesque. Many who object to abortion on ethical grounds maintain that this procedure, like other forms of fetal tissue use, would encourage the practice. Moreover, it seems self-contradictory for a woman to consent to abortion and at the same time consent to become a grandmother. Children created by this procedure, it could be argued, would know little about their genetic heritage or about their mother, other than that she was a dead fetus, and would therefore be at risk of both psychological and social harm.

Female cadavers provide another potential source of oocytes for those who are infertile. It has been proposed that women consider donating their ovaries for use by others after their death, much as individuals donate organs such as kidneys and livers (Seibel). It may soon be possible to collect immature eggs from cadavers, mature and fertilize them in vitro, and then transfer them into infertile women. This procedure would have an advantage over the use of eggs from aborted fetuses in that the recipient would be able to learn the medical and genetic history of the adult donor. An argument for this practice is that it would allow the continuation of the family's biological heritage and serve to console the grieving family because some aspect of their deceased relative will have been preserved. Postmortem recovery of eggs would be done with the consent of the donor and would therefore respect individual rights and allow freedom of choice for individuals and their close relatives.

This proposal is grounded in an analogy between organ and gamete donation. Yet gamete donation is different in that it involves the provision of an essential factor for bringing a child into existence; it is not life-saving but life-giving. The interests of the resulting children, consequently, provide a major consideration to be taken into account in determining whether such procedures ought to be pursued. The difficulty noted earlier in connection with the introduction of third parties arises in this instance as well.

Children develop their identity and self-understanding, in part, through their relationships with their biological parents. Consequently, they might face serious psychological and social harm if one of their biological parents were a cadaver. Indeed, this concern amounts to a central social concern as well, in that the prospect of using gametes derived from the newly dead in order to create children endangers our perception of the respect due to the dead human body and our view of procreation as ideally grounded in an interpersonal relationship between living persons.

Ethical Issues Related to Access and Justice

Although those able to procreate naturally can decide whether and when to do so, the choice to reproduce among those who need medical assistance to do so is more limited. In part, this is because they enter a healthcare system in which providers have responsibilities both to candidates for infertility treatment and to the resulting child, because they are assisting in the creation of a new human being. Although physicians have a special obligation to respect the autonomy and freedom of those who are candidates for treatment, they are not obligated to provide them with all treatments that they request (Chervenak and McCullough). As one of several groups of gatekeepers of the new reproductive technologies, some physicians use a medicalindications criterion to bar access to these technologies to some patients, as when, for example, the physical risk of pregnancy is too great. Yet many physicians find that they cannot easily separate medical indications from indications that are psychological, social, and ethical. Questions requiring judgments that go beyond those that are strictly medical arise in many situations. These questions include possible treatment for candidates who wish to create "designer babies" of a certain sex, intelligence, and/or race; couples who want to use a surrogate mother for frivolous reasons related to personal convenience; infertile single women who request access to both oocyte and sperm donation in lieu of adoption; women of advanced reproductive age who want to have children despite the risk to their own health; and couples who appear severely dysfunctional and prone to violence and child abuse. Physicians are not usually trained to address ethical questions that arise in such situations. Because physicians have personal and professional biases and are part of a largely unregulated and profitable infertility industry, it might be appropriate to assign the gatekeeper role to a specially trained group of professionals who are not physicians. Another possibility is to utilize guidelines for the use of the new reproductive technologies prepared by physician professional associations, institutional ethics committees, private-sector ethics boards, public ethics commissions, and state and national regulatory agencies; such guidelines should address not only medical but social, psychological, and ethical issues (Cohen, 1994; Fletcher).

Public-policymakers and private healthcare insurance regulators also affect who gains access to the new reproductive technologies. If they define infertility treatment as a response to a disease rather than to a social need, a case for financial support of the new reproductive technologies can be made. Because infertility is a physical condition that impairs normal function, many commentators regard it as something like a disease, the victims of which are in need of help from medical science (Overall). However, it can also be argued that since reproductive technologies do not correct the condition causing infertility, they do not constitute medical treatment for a disease. Yet many well-accepted treatments do not correct the underlying condition but only its symptoms or disabilities. Given the importance to many people of having a biological child and the fact that normal functioning allows this, the claim has been made that infertility should be treated as a disease on a par with other physical impairments. Historically, the barren woman or man has not been accorded sympathy; the availability of infertility treatment might disarm similar current discriminatory attitudes toward those who are infertile.

Even if infertility were defined as a disease, however, this would not indicate that its treatment would be ethically mandatory. The U.S. healthcare system does not have infinite resources and cannot provide everyone with every desired or desirable health service. Should the new reproductive technologies be subject to more severe criteria for funding than are set for other medical techniques? Because infertility is a physical dysfunction with significant effects on the life plans of those it affects, it can be contended that a just society should include reproductive technologies among the range of treatments covered. The opposing argument is that the costs of such treatment and its relatively low likelihood of success do not justify its inclusion.

A related issue arises from the fact that only a limited range of people—those with greater financial resources—benefit from the new reproductive technologies. Access depends on economic factors, culture, race, and social class. Those in the United States who are poor have little access to specialty services such as infertility clinics because public and private insurers provide limited coverage. If poor people participate at all in the use of these technologies, they do so as surrogates or occasionally as oocyte donors. Thus, the use of new reproductive technologies has potential for creating further unjust schisms in our society between rich and poor and between one subculture and another. As long as IVF services and gametes are in short supply, questions will arise about how to select candidates from among those who seek access to the new methods of assisted reproduction. Those persons who are infertile or who carry a serious genetic disease may have a greater first claim than those who are not infertile but who wish to use these methods to select the features of their children or as a matter of personal convenience.

This is because the need of the former is a more basic need, directly related to the goal of remedying a difficulty in normal species functioning. A more refined set of rationing priorities would take account of such factors as the number of children an individual or a couple already has; whether they have a support system in place to assist them to care for a child adequately; and the greater medical risk to certain recipients of treatment, such as women of advanced reproductive age. These considerations would be grounded in the interests of the potential children and of their would-be parents, as well as in the need to distribute the number of children among couples in an equitable way.

Conclusion

Behind many of the ethical issues raised by the new reproductive technologies lie difficult questions about the importance of genetic parenthood, the nuclear family, and the welfare of children, as well as the role that society should play in overseeing the creation of its citizens. Perplexity about how to resolve these questions is due, in part, to the speed with which these technologies are being developed. There is a growing concern that they are being created too rapidly, before the old technologies, such as artificial insemination, have been integrated into the ethical and social fabric. As the rate of reproductive change accelerates, the ability to provide ethical safeguards for the creation and use of the new reproductive technologies diminishes. This may be the most persuasive reason to provide some form of direction and regulation of the new reproductive technologies that incorporates defensible ethical limits to their use.

cynthia b. cohen (1995)

bibliography revised

SEE ALSO: Abortion; Adoption; Cloning; Embryo and Fetus; Eugenics; Feminism; Fetal Research; Fertility Control; Genetic Counseling; Genetic Testing and Screening: Reproductive Genetic Testing; Healthcare Resources, Allocation of: Micro-allocation; Law and Bioethics; Maternal-Fetal Relationship; Moral Status; Organ and Tissue Procurement: Ethical and Legal Issues Regarding Living Donors; Population Ethics; Sexism; Transhumanism and Posthumanism;Women, Contemporary Issues of; and other Reproductive Technologies subentries

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