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Ethical Issues of Reproductive Technologies: Designer Babies, Sex Selection and Donor Babies

Rachael Caffrey, 5th Year Medical Student, Queen's University Belfast

Address for Correspondence: School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, 71-73 University Road, Belfast BT7 1NN. Email: [email protected]

The technology of assisted reproduction has progressed rapidly in recent years, enabling infertile couples to have the children they long for. However, with these advances come numerous ethical dilemmas .This essay looks at three important areas of reproductive technologies; `designer babies', sex selection and `donor babies', which all raise their own ethical issues; ethical arguments for and against each are discussed. `Designer babies' describes the use of several technologies, particularly Pre-implantation Genetic Diagnosis, which give parents an element of control over their offspring's characteristics. The dilemma is whether it is ethical to design babies by selecting an embryo in this way. The main argument for these techniques is that they can help prevent certain genetic diseases. The main argument against is that of the `slippery slope' towards designing babies for physical or psychological traits. Sex selection for medical reasons is largely accepted as ethical, but when carried out for non-medical reasons, is met with objections. The case for permitting sex selection for non-medical reasons is that it serves the desires of couples who have strong preferences regarding the gender of their offspring. However, this raises worries regarding gender discrimination and inappropriate use of medical resources. `Donor babies' refers to the use of donated gametes by infertile couples. There is much debate on the acceptability of gamete donation in circumstances where infertility is due to psychosocial factors e.g. in lesbian couples or post-menopausal women. A major argument against oocyte donation to older women is that there is a `natural' limit to reproductive capacity and 87

to transcend this would be `unnatural', balanced against an argument of `reproductive freedom'. New reproductive technologies are helping infertile couples have the children they yearn for, and additionally, are saving lives and preventing disease. However, there are clearly many ethical issues and contrasting viewpoints to consider with regards to these technologies, and it must be remembered, that regulation is important to avoid the use of these powerful technologies for inappropriate purposes. J NI Ethics Forum 2008, 5: 87-96 Introduction The technology of assisted reproduction has progressed at a rapid pace in recent years, enabling many otherwise infertile couples to have the children they long for.[1],[2] Conception, pregnancy and childbirth, formerly an indivisible process, can now be considered as separable stages of reproduction.[3] With these advances however, come numerous ethical dilemmas. In this essay I will look at three areas of reproductive technologies; `designer babies', sex selection and `donor babies', and discuss the ethical arguments for and against each one. Designer Babies `Designer babies' is a term that has become part of everyday language, though it was a term initiated by journalists rather than scientists.[4],[5] It describes the use of several reproductive technologies, all with one thing in common; they give parents an element of control over the characteristics of their offspring.[5] The technique at the centre of the debate about designer babies is Pre-implantation Genetic Diagnosis (PGD), which brings together two technologies: in vitro fertilisation (IVF) and genetic testing.[4] The dilemma is whether it is ethical to design babies by selecting an embryo in this way.[5] The main argument for these techniques is that they can help prevent certain genetic diseases e.g. single gene disorders such as cystic fibrosis, and chromosomal 88

abnormalities such as Down's Syndrome.[6],[7] In this way they can save children from debilitation and suffering and reduce the financial and emotional strain on the parents.[6] Furthermore, Verlinsky[5] tells us these techniques are used only by those requiring the help of a fertility clinic to have children, and therefore argues that since these people have invested so much time, energy and money in their effort to have a baby, shouldn't they be able to ensure they have a healthy child? Another point to be noted is that many naturally conceived embryos are rejected from the womb due to disordered growth, and so it can be argued by screening embryos we are simply doing what nature would normally do.[5],[6] However, one argument against using PGD to prevent disease is that of the `slippery slope' argument. The worry is that we could get carried away `correcting' babies.[6] The Human Fertilisation and Embryo Authority (HFEA), who regulate the use of PGD, state that it should only be used for detecting "very serious, life threatening conditions" and not for minor abnormalities, but `serious' is difficult to define in this context.[7] Where do we draw the line? Furthermore, from a disability equality perspective, every life is of value and our diversity as a species has innate value. Therefore, to discriminate against an embryo, which could go on to become a person with a disability or disorder would be considered wrong.[8] Moreover, once on this slippery slope what is to stop us choosing babies for their physical or psychological traits?[5] The path from therapy to enhancement is a continuum rather than a clear and obvious dividing line.[9] It is argued this could be the first step towards allowing parents to choose other characteristics of their baby such as eye or hair colour.[10] There is always the looming shadow of eugenics and `improving' the gene pool by the elimination of `undesirables', in this case, undesirable embryos.[5] On the other hand, opposing this argument is the fact that merely asserting that this is the first step towards allowing parents to choose 89

other characteristics is inadequate.[10] Through the use of careful regulations PGD could be used for some reasons and not for others, thereby avoiding a `slide down the slope'.[10] One form of `designing babies' I have not yet considered is that of using PGD in conjunction with tissue typing to select an embryo for implantation that will go on to become a `saviour sibling'; a brother or sister capable of donating lifesaving tissue to an existing child.[10] An argument particular to this technique is that saviour siblings would be treated as mere commodities, not wanted for their own sake, but for some other purpose.[10] In the words of Kant's famous dictum, "Never use people as means but always treat them as a end".[7] However, in reality many children are born for a purpose: as a companion to a sibling, to `pass on the family name', or bring happiness to the parents. Therefore, providing parents love their child, it is argued there is no harm in that child benefiting another.[7] Having discussed these issues I feel that using PGD is something that should not be done without careful consideration on behalf of the parents involved. Choosing which embryo to implant and which to discard is not an easy choice, nor should it ever be.[11] Nonetheless, in my opinion any technology that can reduce pain and suffering is one to be considered, be that by preventing a life of suffering or by easing the anguish of an existing child. By the implementation of regulations I believe this technology could be used for good, and any trivialisation of the technique to `design babies' for cosmetic traits could be prevented. Sex Selection Another issue to consider is that of sex selection. The two main techniques used for this are, again, PGD or alternatively, sperm sorting. The HFEA's recommendation is that sex selection should only be available "in cases in which there is a clear and overriding medical justification", referring to the avoidance of sex-linked genetic conditions such as Tay-Sachs.[12] The British Medical Association is concurrent with this.[13] The main focus of ethical objections to this technique are linked 90

with sex selection for non-medical reasons, with there being less debate over the ethical validity of sex selection when its aim is to prevent the transmission of sex-linked disease.[14] Taking this into account, and as I have already discussed the use of PGD to avoid genetic diseases, we are presented with questions such as: if a couple have two sons and desire a daughter, should they be allowed to employ this technology?[15] The case for permitting sex selection for non-medical reasons is that it serves the desires of couples who have strong preferences regarding the gender of their offspring, some of whom feel so strongly they may resort to abortion or choose not to procreate unless the gender of their future baby can be determined.[16] Then again, one can question whether desire alone justifies acceptance of their preference, especially when it is a preference which is often self-imposed.[16] One suggested argument against the use of this technology in this way is that it constitutes an inappropriate use of medical resources. However, according to the American Society for Reproductive Medicine (ASRM) preconception gender selection (i.e. sperm separation followed by artificial insemination) is unlikely to drain substantial resources from the medical system.[15] Another ethical issue surrounding sex selection is that of gender discrimination and, furthermore, that offspring produced will be expected to act in certain gender specific ways.[15] Some argue that although the motivations for desiring a child of a particular sex vary, other than in the case of preventing a sex-linked disease, there are no nonsexist reasons for pre-selecting sex.[15] Furthermore, there is the worry that sex-selection will lead to adverse social consequences due to an unbalanced sex ratio. It is likely though that only a small percentage of the population would request sex selection, therefore the impact on the sex ratio would be minimal.[1] Alternatively, if sex selection were to become very popular, laws could be introduced requiring providers to select both genders in equal numbers thereby avoiding a shift in the sex ratio. Although it could then be argued that the institution of laws in this way would result in a decrease in procreative liberty and defy the purpose of the procedure! [15] An alternative argument against sex 91

selection is based on the parental virtue of acceptance. When an individual becomes a parent society expects him or her to maintain that role regardless of the specific characteristics of their child.[12] McDougall[12] proposes that it is an intrinsic feature of a child that his or her characteristics will be unpredictable. Even if their entire genetic make-up were known, the complexity of the child's environment makes their characteristics, to some extent, unpredictable. Therefore, it follows, since a child's characteristics are unpredictable, acceptance of those characteristics is a parental virtue.[12] A child's sex would fall within the scope of this parental virtue of acceptance and on this basis sex selection would be regarded as wrong. McDougall[12] does acknowledge however, that acceptance is only one in a range of parental values and others, such as concern for a child's opportunities, can conflict with this. Whilst I recognize that sex selection would satisfy the desires of couples to `balance' their families, I feel that other than in exceptional circumstances, sex selection should only be available for medical reasons. I believe concern with gender, be that male or female, is not something to be encouraged.[16] Gender is not a medical condition, but rather, a characteristic to be accepted by parents. Therefore, I see no compelling argument to justify the use of this technology for social reasons. Donor Babies A final area to look at is that of `donor babies' or the use of donated gametes. For infertile couples who lack sperm or oocytes this may be the only solution to enable the accomplishment of a parental offspring.[17] Gamete donation was introduced to address various medical problems, and is indicated where there is no possibility of pregnancy without the technique, or when other treatments have a minimal chance of success.[1],[17] Such circumstances include the use of donated oocytes where a woman has suffered premature ovarian failure or because treatment such as chemotherapy has rendered her infertile.[18] It can 92

also be used to evade transmission of a genetic disease to the offspring.[17] These uses all fall into the realm of medical treatment and pose no unique ethical problems. Major ethical issues arise however, when the practise is used for non-medical reasons. There is much debate on the acceptability of gamete donation in circumstances where the infertility is due to psychosocial factors such as, in, lesbian couples or post-menopausal women.[19],[17] It is this use for older, post-menopausal women that is often debated and the area that I will focus on. Oocyte donation has been used for infertile women over the age of forty when IVF with their own oocytes has been unsuccessful and there is no explanation other than age for their infertility. The use of younger women's donated eggs proved highly successful and paved the way for their use in postmenopausal women. [1] In this way a woman's reproductive age has been artificially extended.[19] A major argument against oocyte donation to older women is that there is a `natural' limit to reproductive capacity and to transcend this would be `unnatural'.[19] Furthermore, parenting can be a physically demanding, energyconsuming task and it is thought that older parents may be unable to meet the needs of a growing child.[1],[19] However, it can be pointed out that it is not unusual for children to be raised by grandparents and it is therefore put that older people are capable of fulfilling parental roles.[1] Arguments in favour are based on gender equality and reproductive freedom. It is argued that since older men may father children naturally, denying woman an alternative to reproduction at the equivalent age is sexist, especially since women generally live longer than men.[19],[20] However, there are real concerns regarding the health of the recipients. In a postmenopausal pregnancy the woman faces increased risk of complications such as hypertension, diabetes, and preterm labour. [19] There are also concerns surrounding the interests of the child who, some feel, may be adversely affected psychologically and socially, and may resent having a mother old enough to be their grandmother.[19] In addition, there is the concern that there is increased likelihood that one or both parents will die before the child is raised.[1] Nonetheless, it 93

should be noted that individuals with life-limiting illnesses are not prohibited from reproduction because of their shortened life expectancy.[19] In addition, Strong[1] makes the point that if a couple were to have a child at the age of 60, on average the life expectancy for the woman would be another 23 years, and for the man, another 19 years. Thus, on average the child would be a young adult before its parents died. Having considered the above arguments I feel we cannot say absolutely that oocyte donation to older post-menopausal women is `right' or `wrong'. Whilst it can be argued that infertility should remain the natural characteristic of the menopause, I do not consider this reason persuasive enough to deem the practice unethical in every case.[19] There are many factors we have to take into account, such as the woman's age, health, and personal circumstances. The specifics of each case should be carefully considered by the prospective parents and physician involved before choosing oocyte donation.[19] Conclusion There are clearly many ethical issues to consider with regards to reproductive technologies and many viewpoints to be looked at, all of which cannot be included in the constraints of this essay. New reproductive technologies are helping infertile couples have the children they yearn for, and additionally, are saving lives and preventing disease. The good it will bring about is the moral motive for intervening in the natural lottery of life.[21] It must be remembered however, that regulations must be set in place to avoid the use of these powerful technologies for inappropriate purposes.

Rachael undertook the 2nd Year Student Selected Component `Reproductive Technology" co-ordinated by Professor Sheena Lewis, School of Medicine, Dentistry and Biomedical Sciences, QUB in spring 2006 and was joint runner-up in the Forum's 2006 Essay Competition.

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References [1] Strong C. Ethics in Reproductive and Perinatal Medicine. Yale University Press, New Haven, 1997 [2] Haase J. Gamete and Embryo Donation: The Need For Regulation. Adoption Council of Canada. http://www.adoption.ca/viewpoints/gamete.htm (Accessed 9 April 2006) [3] Van Dyck J. Manufacturing Babies and Public Consent: Debating the New Reproductive Technologies. Macmillen, Basingstoke, 1995 [4] Lee E. Introduction. In: Institute of Ideas. Designer Babies: Where should we draw the line? Hodder and Stroughton, London, 2002 [5] Verlinsky Y. Designing Babies: what the future holds. Ethics, Law and Moral Philosophy of Reproductive Biomedicine 2005; 1(1): 24-26 [6] Centre for the Study of Technology and Society. Biotechnology Special Focus ­ Designer Babies. http://www.tecsoc.org/biotech/focusbabies.htm (Accessed 23 February 2006) [7] Boyle R, Savulescu J. Ethics of using preimplantation genetic diagnosis to select a stem call donor for an existing person. British Medical Journal 2001; 323(7323): 1240-1243 [8] Fletcher A. Making it Better? Disability and Genetic Choice. In: Institute of Ideas. Designer Babies: Where should we draw the line? Hodder and Stroughton, London, 2002 [9] English V, Sommerville. Drawing the Line: The Need for Balance. In: Institute of Ideas. Designer Babies: Where should we draw the line? Hodder and Stroughton, London, 2002 [10] Sheldon S, Wilkinson S. Should selecting saviour siblings be banned? Journal of Medical Ethics 2004; 30: 533-637 [11] Stock G. Germinal choice technology and the human future. Ethics, Law and Moral Philosophy of Reproductive Biomedicine 2005; 1(1): 27-35 95

[12] McDougall R. Acting parentally: an argument against sex selection. Journal of Medical Ethics 2005; 31: 601-605 [13] Doyal L, McLean S. Choosing children: intergenerational justice? Ethics, Law and Moral Philosophy of Reproductive Biomedicine 2005; 1(1): 24-26 [14] The Ethics Committee of the American Society of Reproductive Medicine. Sex selection and preimplantation genetic diagnosis. Fertility and Sterility 2004; 82(1 Suppl): 245-248 [15] Cloonan K, Crumley C, Kiymaz S. Sex Selection: Ethical Issues. Developmental Biology Online, 2003 http://7e.devbio.com/article.php?id=177 (Accessed 25 March 2006) [16] The Ethics Committee of the American Society for Reproductive Medicine. Preconception gender selection for non-medical reasons. Fertility and Sterility 2004; 82(1 Suppl): 232-235 [17] ESHRE Task force on Ethics and Law. Gamete and embryo donation. Human Reproduction 2002; 17(5): 1407-1408 [18] The National Gamete Donation Trust (NGDT). Egg donation. NGDT, 2002. http://www.ngdt.co.uk (Accessed 8 April 2006) [19] The Ethics Committee of the American Society of Reproductive Medicine. Oocyte donation to postmenopausal women. Fertility and Sterility 2004; 82(1 Suppl): 254-255 [20] Sauer M, Paulson R, Lobo R. Pregnancy in women 50 or more years of age: outcomes of 22 consecutively established pregnancies for oocyte donation. Fertility and Sterility 1995; 64: 111-115 [21] Harris J. Reproductive liberty, disease and disability. Ethics, Law and Moral Philosophy of Reproductive Biomedicine 2005; 1(1): 13-16

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