Het is echter wel schadelijk om overmatig te alcohol te drinken, zeker als u een infectie heeft. Dit komt de infectie eerder verergerd door het gebruik van alcohol antibiotica kopen Doorgaans worden ze voorgeschreven bij bacteriële infecties die om de één of andere reden niet uit zichzelf over gaan; ze doden dan de bacteriën.
C:\docume~1\svetli~1.sve\mydocu
Ethical issues arising from the use of assisted reproductive technologies Introduction
warrant attention, balance and prioritization. Balanceand prioritization may be achieved in different ways,
The purpose of this paper is to address ethical issues
depending upon the ethical orientations, principles
arising from four aspects of the employment of
and levels of analysis that are brought to bear. For
assisted reproductive technology (ART), namely:
instance, deontological or principle-based orienta-tions may produce different outcomes from utilitarian
or consequentialist orientations, ethical principles
• the establishment and change of social policies;
such as beneficence and justice may be ordered in
• commercialization of human gametes and embryos;
different priorities, and interpersonal or microethics
may justify different results from public or macro-
Different conclusions can be of equal ethical merit,
Issues will be considered in this sequence, but
related to the different factors that contribute to
they are not entirely separate from each other. There
undertaking ethical reflection. For instance, much
is unavoidable overlap among them, and some topics
consideration of ART involves gamete and embryo
may fit as well under the headings of two or more
donation, but in the Islamic tradition, where con-
issues. Similarly, there is some overlap among issues
ceiving children and raising them in religious faith are
addressed in this and the other background papers
particularly important values, so too is the integrity
on ethical and social concerns in this publication.
of a family’s genetic lineage (2). Accordingly, in this
Accordingly, for the sake of convenient analysis,
context, gamete and embryo donation from outside a
topics will be presented under headings and sub-
married couple is ethically unacceptable, but within a
headings, but they are not to be considered as
marriage artificial techniques may be employed to
discrete from each other. Some discussions will relate
achieve pregnancy. In contrast, the Roman Catholic
to others in different sections of the paper, and in
branch of Christianity limits acceptable human
other papers. Further, the thrust of some discussions
reproduction to natural intercourse between a married
may appear to vary from and even contradict that of
couple (3), but may tolerate transfer of a donated
others. This is because ethical analysis does not
ovum to an infertile woman’s reproductive system for
necessarily lead to a self-determined conclusion;
natural insemination there by her husband. Artificial
rather, it exposes considerations that require or
conception may therefore be ethically available to a
Muslim but not an observant Roman Catholic couple,
consent and the prohibition of incest. The mature and
and ovum donation may be ethically available to a
responsible are not privileged over the immature and
Roman Catholic but not an observant Muslim couple.
irresponsible, nor the wealthy over the poor or the
Within some religious faiths, ethical pluralism is
healthy over the infected, but all rank equally as
rejected, and divergence from authoritative doctrine
individuals able to exercise choice of reproductive
may be deemed heresy. The modern practice of ethics
behaviour according to their own preferences and
or bioethics is secular and pluralistic, however ( 4 ),
recognizing that ethical reasoning on the same issue
In contrast to the capacity of usually fertile
can justify different conclusions. This is not to say
individuals to undertake consensual reproductive
that every option is acceptable, but that adherents of
behaviour in private, is the public attention and
one preferred outcome may well acknowledge that
regulation to which reproductively impaired indivi-
adherents of an alternative preferred outcome are
duals are increasingly subject when they propose
applying approaches that result in different ethical,
resort to ART. Particularly in developed countries
where ART techniques have been pioneered, such asAustralia and the UK, state and national commissionswith distinguished memberships have proposed
The principle of equity
criteria by which ART may become restrictivelyavailable to reproductively impaired people. Proposals
Equity and equality
of many commissions have been enacted into laws oradopted as professional or clinical practices. These may
Equity is distinguishable from equality, although the
limit access to ART to legally married or cohabiting
two often coincide. Equality requires the identical
heterosexual couples in relationships of specific
treatment of all despite their differences, whereas
duration, require or facilitate their scrutiny according
equity requires equally fair treatment of individuals
to medical, genetic and perhaps psychological stand-
taking account of ethically significant differences
ards, or screen them by reference to other criteria such
among them. The ethical principle of justice requires
as age, personality and criminal or childcare history.
that like cases be treated alike (hence the legal pre-
An ethical concern is the extent, if any, to which
occupation with precedents) and that different cases
different approaches towards reproductively impaired
be treated in ways that acknowledge the differences,
and unimpaired people, established in law or practice,
raising ethical concerns of likeness and difference. For
can be justified. An important human rights provision
instance, the private insurance industry in the USA
is nondiscrimination on grounds of physical and
has long treated men and women as equals in covering
mental disability, according to which reproductively
contraceptive services for neither. However, women
disabled people should be placed at no disadvantage
bear the consequences of, particularly unplanned,
in contrast to people of usual fertility. Another provi-
pregnancy more directly and oppressively than men.
sion is to ensure due protection of children, however,
The inequity of this equality became clear when
which allows, for instance, lawful removal from their
insurance companies speedily extended their cover to
parents’ care of children exposed to or at serious risk
include the new male potency drug Viagra (5), moving
of abuse or neglect. This provision may afford an
some state legislatures to require coverage of
ethical justification of laws and practices that bar or
scrutinize access to ART of people whose circum-
An initial issue of equity and equality concerning
stances or histories furnish credible apprehension
ART is whether people with impaired fertility,
that, even unintentionally and despite their good will,
including those who turn to ART because their natural
any children for whose care they became responsible
reproduction would expose their children to un-
would be at risk of serious disadvantage or neglect.
acceptable risks of harmful genetic inheritance, should
The ethical principle of respect for persons balances
be as free to reproduce as people of usual fertility. In
rights of autonomy against rights to protection of
many countries and cultures, particularly of the western
vulnerable persons, of whom young, dependent
world, the latter are not subject to legal prohibitions,
requirements of marriage or, for instance, medical
The goal of serving the best interests of prospec-
screening on genetic or other grounds, although they
tive children is sometimes invoked to justify limiting
are subject to the regular law on their partners’ capable
people’s access to ART, even though the consequence
Ethical issues arising from the use of assisted reproductive technologies
may be that the prospective children whose interests
usually fund diagnostic services, and may fund drug
are claimed to be protected are never conceived. The
and surgical treatments, such as of diseased fallopian
inequality or inequity of controlling the reproduction
tubes, that restore fertility, but not ART that does not
of infertile people who are dependent on ART, when
reverse the medical condition of infertility but over-
that of usually fertile people is not and perhaps cannot
comes it by artificial means of conception.
be controlled, is sometimes explained on pragmatic or
The ethical and related human rights principle of
utilitarian grounds, and by recognition that, in many
nondiscrimination on grounds of disability raises the
countries, fertile people whose parenthood exposes
question of whether states should ethically do more
their children to undue risks will be subject to child
than to permit those with the personal means to avail
protective intervention that denies them childrearing
themselves of accessible ART services to do so; that
opportunities. However, the children of fertile couples
is, whether ART should be allowed as luxury medi-
are not legally removable from their care on the ground
cine, like, for instance, cosmetic surgery, available with
only that public agencies believe that they can better
minimum screening on social or moral grounds to those
serve the children’s “best interests” by placing them
with the means of purchase, or whether the principle
elsewhere, and it appears inequitable to invoke a “best
of equity requires some measure of public funding or
interests” criterion legally to deny ART to infertile
subsidy of ART services, such as by taxation relief
couples when there is little risk of their future children
for its cost. States that provide publicly funded health
care services to restore natural capacities, includingreproductive capacities, may claim that they satisfy
Disability and pathology
their duties of equity in treating all eligible recipientsof state medical services alike, and that they have no
Impairment of fertility may be due to a pathological
further ethical responsibilities to those that ordinary
cause, but it is ethically contentious to describe people
care cannot assist. It may be that medical treatment
seeking access to ART generically as unhealthy or
of pathological conditions that cause infertility, such
diseased people, or, indeed, apart from their impaired
as premature menopause and fallopian tube blockage,
reproductive capacity, as disabled. Infertility itself is
discharges the duty of health care equity, and that
not a disease, and alone it does not impair medical
there is no such duty to relieve remaining disability by
health, although among those who want to have their
provision of costly ART services. Nevertheless, limited
own genetically related children it may impair their
access to ART services due to their high cost remains
health in so far as the World Health Organization
a major equity issue raising questions about reproduc-
recognizes “health” as a state not only of physical well-
tive rights of people with limited financial means.
being but also of mental and social well-being. On thisbasis, UN conferences have endorsed the definition
Negative rights and positive rights
that: “Reproductive health is a state of completephysical, mental and social well-being and not merely
Considering impaired fertility as a reproductive
the absence of disease or infirmity, in all matters relat-
disability raises the concern of the appropriate public
ing to the reproductive system and to its functions
or macroethical response to the rights of such disabled
and processes. Reproductive health therefore implies
persons to equitable treatment. Rights are often
that people are able to have … the capability to
contrasted by reference to negative and positive rights.
reproduce and the freedom to decide if, when and how
Negative rights amount to rights to be left alone,
often to do so. Implicit in this last condition are the
whereas positive rights require that holders be provi-
right of men and women to be informed and to have
ded, often by state agencies, with means to exercise
… the right of access to appropriate health-care
such rights. Rights to luxury goods and services are
services that will … provide couples with the best
usually considered only as negative rights. By
chance of having a healthy infant” (7).
analogy to transportation, governments may provide
Infertility can deny mental or social well-being and
low-cost or subsidized public transit services by road
be a cause of acute affliction and anguish, evidenced
and rail to take people to and from work and between
by the extent of physical and financial cost individuals
major population centres, but not maintain rural
are willing to bear for its relief. However, many
transit networks, provide subsidized airline services,
countries that provide publicly funded health care for
or provide motorized vehicles for private use. Similarly,
medically necessary services do not fund ART. They
they may provide routine, low-cost treatment for
pathological causes of infertility and limited higher-
result from natural or medically assisted procreation,
cost care for more resistant conditions, but not the
but many mental disorders are transient, of different
more expensive forms of ART. They may explain this
levels of severity and amenable to treatment. It has
in terms of health care economy, and also by reference
been observed that “The stigma suffered by the
to cost-effectiveness considerations in the budgeting
mentally ill dates back to antiquity and has its origins
in fear, lack of knowledge and ingrained moralistic
The negative right to ART, meaning individuals’
views. Though erroneous, these associations remain
right to acquire access by their own resources,
pervasive…. At times, the unusual and even un-
requires that state and other agencies forbear or
founded nature of psychiatric theories and the
restrain themselves, or be restrained by judicial or
practitioners who uphold them has compounded the
other lawful means, from undue intervention by their
problem” ( 9 ). Equity requires that particular appli-
creation of barriers or obstacles to equitable access.
cants for ART be clinically assessed on their indivi-
Many of these barriers have been of a moral nature,
dual merits, and not be denied rights of access on
prohibiting individuals from unfettered resort to both
grounds of impersonal, collective stigmatization and
publicly funded and privately available ART services.
Some initial reactions to novel means of conception
ART applicants’ liability to exclusion on grounds
have exhibited what has been described as “moral
of their physical health should similarly be clinically
panic”‚ meaning an unreasoning fear of subversion
assessed. Their vulnerability to premature death or
of the moral order. It was noted in 1991 that “While
disability, leaving young children at risk of orphanage,
the past 40 years has seen the meltdown of the nuclear
destitution or neglect, may properly weigh negatively
family and its surrounding myths and ideologies—in
in the balance, but rights of access should not be
less than ten years half of all children born in the
denied on the basis of negative stereotyping. The
United Kingdom will be brought up outside the
British Medical Journal has recently observed, for
‘conventional’ family—new demons, chimeras and
instance, that in view of the prolonged life expectancy
spirits have been summoned to haunt the new families
of people who are HIV-positive and receiving treat-
which technological and personal upheavals have
ment now available, particularly in developed
countries, there is no justification for denying infertil-
For instance, unmarried individuals, including
ity treatment to patients who bear the infection. It
single people and partners in same-sex relationships,
reported that “Judicious use of combination anti-
have been barred from ART by laws or by institutional
retroviral therapy during pregnancy and labour,
or professional rules or practices. These have been
delivery by caesarean section, and avoidance of
based on or reinforced by claims that limits are
breastfeeding are proved measures which have
compelled or justified to protect children against births
reduced the risk of vertical transmission to less than
into unstable or otherwise unconventional domestic
2%” (10). Exclusion of HIV-positive applicants from
settings. These speculative claims may be un-
ART programmes may be explained not by their
supported by empirical data, however, such as is
incapacities to be suitable parents, but by health care
available of the harms suffered by children that live
practitioners’ inequitable reluctance to treat them as
in violent homes. Comparable claims that have denied
rights to adoption of children are now yielding in many
countries to recognition that children are as well reared
surplus embryos may be liable to comparable negative
in less conventional as in more conventional home
stigmatization, for instance when gay men are rejected
environments. It is increasingly recognized that more
as sperm donors, it is doubtful that they have an
than conservative orthodoxy and negative speculation
ethical or equitable right of donation. The question is
based on generic bias are required to deny a right of
sometimes posed of, whether human tissue donors,
for instance‚ of blood for transfusion or creation of
Preconceptions about the unsuitability and
plasma products, have a general right or only a
ineligibility for access to ART of those affected by
selective privilege of donation. Egalitarians tend to
mental disorders may also require reconsideration on
favour the former in light of the humiliation and loss
grounds of equity. Mental disorder of a severe nature,
of self-esteem those whose altruistic offers of
although not requiring institutionalization, may justify
donation are rejected may suffer. The right/ privilege
ineligibility for a childrearing role, whether children
distinction may be a false dichotomy, however, since
Ethical issues arising from the use of assisted reproductive technologies
donation may be neither a right nor a privilege, but
tion and birth of children has customarily been
only a qualified opportunity; that is, an opportunity
regarded as a private or family matter, regulated by the
to offer to satisfy objectively, scientifically justified
unpredictable chance of nature or as a divine mystery
criteria of eligibility. For instance, a couple may be
outside decisive human control. The principles of
admitted to an ART programme as suitable, informed
family law within a community reflect its most historical
recipients of the service, but not be eligible on genetic
and customary or intuitive values, often embedded in
or other grounds to donate their gametes or surplus
religious beliefs regarding private intimacy, associated
embryos to others. They have no ethical rights of
with the transition between generations of family
donation, but only the right to offer to donate (see
the chapter on “Gamete and embryo donation” for
The emergence of ART including gamete donation
details on the criteria of acceptability).
has confused the genetic cohesion and integrity of
A related question is whether recipients of ART
traditional family identity (15), and initially triggered
services can claim a right to choose specific gamete
conservative responses. First reactions to what
or embryo donors. With the exception‚ for instance‚
reproductive technology shows to have become
of the wife of an infertile couple choosing her brother
possible are often more instinctive or visceral than
as a sperm donor, couples may claim a right of choice
intellectual, and policy responses have tended to
of donors who meet routine criteria, such as being
focus more on defence against perceived dangers to
HIV-negative. It has been reported regarding ovum
traditional values than on achieving potentials for
donation, for instance, that “90 percent considered
human satisfaction and cultural enrichment through
using a sister, 76 percent decided that a sister would
new applications of biotechnology. This was observed
be the preferred donor, 70 percent asked a sister to
with the early popularization of artificial insemination,
donate, and 60 percent found a sister to be willing”
when Kleegman and Kaufman noted in 1966 that:
(12). Ethicists and practitioners have raised theconcern that family relationships may become blurred
or confused by the use of such known donors (13),
emotionally charged area has always elicited
and issues of blame or regret may arise if donation is
a response from established custom and law
followed by an adverse outcome. Allowing ART
of horrified negation at first; then negation
patients to recruit donors also raises concerns of
financial inducements, emotional coercion and
curiosity, study, evaluation, and finally a very
exploitation of dependent relationships. The New York
slow but steady acceptance (16).
State Task Force on Life and the Law recommendedthat: “When known egg donors are used, informed
Societies progress through this transition at
consent to donation should take place outside the
different paces, and establish and change their
presence of the recipient. Physicians should attempt
policies accordingly. Those most influenced by
to determine whether known donors are motivated by
religious concepts are in some ways slowest to
undue pressure or coercion; in such cases, the physi-
progress. For instance, since the Roman Catholic
cian should decline to proceed with the donation. When
Church adopted the concept of papal infallibility in
applicable, the informed consent process should
1870, its teachings cannot contradict earlier papal
include a discussion of the psychological and social
pronouncements made ex cathedra , and much of its
ramifications of egg donation within families” (14).
scholarship is devoted to assertion of the authorityof conclusions reached in earlier times. Doctrinal
Establishing and changing social policies
reassessment within the church is severely compro-mised, because it has to be shown consistent withexisting authority. Social policies that reflect any
Policy evolution
variation from church doctrine, such as the doctrinethat artificial or “unnatural” means of achieving
The ethical conduct of a “social policy” suggests
human conception are illicit, are considered a scandal
pursuit of a principled, deliberative public programme
or heresy, and strongly opposed. Indeed, it has been
of action designed to serve the interests of a given
explained that the modern emergence of secular,
organized population or society, according to the
pluralistic western bioethics was strongly influenced
science of politics or statecraft. However, the concep-
by the Vatican’s intransigence in 1968 on doctrinal
reform regarding artificial contraception (17). In
truly informed consent to gestation and childbirth
contrast, although Islamic prohibition of gamete and
could not be given by a woman lacking this experi-
embryo donation is firm, the use of ART to overcome
ence. Others were fearful of the psychological harm a
infertility within marriage is accepted, often welcome
young child might suffer from recognizing that its
and even considered necessary (18).
mother is willing to give away her child to others, and
Different popular religious attitudes to relations
urged that women with dependent children be
between human beings and their perceived divine
prohibited from surrogate gestation (21).
creator can influence policy responses to ART. Inmany Christian communities, for instance, it is
Policy (reform) commissions
considered offensive and a condemnation that oneshould assume to “play God” with human conception
Nevertheless, the advent of surrogate motherhood
and birth, as an impertinent human arrogation of
illustrated an ethically defensible process to establish
divine power and authority. Accordingly, social policy
social policy, to evaluate whether existing policy is
treats the practice of ART conservatively as bordering
dysfunctional or inadequate to address new technical
on impropriety, and detracting from or tampering with
possibilities, such as arise from ART, and to change
the awe and humility with which to face divine
it if necessary. From the late 1970s, many countries
authority. In other religious traditions, however, such
and states and provinces such as those of Australia,
as Judaism, there is a perceived partnership between
Canada and the USA, established governmental or
humans and their divine creator, so that individuals’
other official enquiries into ART, to propose social
“God-given gifts” of skill and initiative are properly
policy responses to limit, accommodate and/or
employed in scientific advance and in the cure or
monitor effects of these new biotechnological
overcoming of medical impairments, including by ART.
capacities on human reproduction and the founding
In this tradition, the divine creator is described as
of genetically diverse families (12,21–29) . They
acting in ways of beneficence, mercy and compassion,
tended to be composed of members of mixed social,
and “the human being is required to imitate God in this
academic, philosophical, religious and other back-
respect” (19). Social policy in Israel, for instance, is
grounds who were experienced in development of
strongly pro-natalist (20) , and encourages ART
social policy. They received representations from
within marriage, provided that ovum donors to Jewish
community groups and individuals, solicited informa-
couples are Jewish, in accordance with the first
tion and opinions they considered necessary or
direction given to Adam and Eve in the biblical Book
appropriate to fulfil their mandates, and consulted with
of Genesis, chapter 1, verse 28, to “be fruitful and
specialists in technical areas and on social and ethical
multiply, and fill the earth,” reinforced perhaps by
implications of policy options. They tended not
demographic and geopolitical incentives.
explicitly to invoke the language or categories of
Problematic and constricting though religiously
ethical discussion, speaking instead of the social
conditioned social policy may be, it has the ethical
values and pragmatic considerations they considered
advantage over purely secular policy development of
significant, but their discussions and conclusions
invoking profound and enduring principles. In
contrast, secular policy-making is more pluralistic but
The conclusions and array of recommendations
may seem to defy the ethical principle of justice in
that these commissions produced did not always win
producing quite different responses to the same
favour with ethical analysts, and were often greeted
circumstance, influenced by idiosyncratic values and
with dismay both by libertarians and by many who
priorities and introduced as a consequence of political
assessed them from conservative religious perspec-
power rather than of any transcending ethical principle
tives. This was because they tended to recommend
or even conscious tolerance of ethical pluralism. When
acceptance of some practices, such as unpaid gamete
surrogate motherhood rose to public visibility, for
and surplus embryo donations, prohibition of others,
instance, and women were recognized as potentially
such as commercial transactions including surrogate
willing to gestate and surrender children to serve other
motherhood agreements, and, for instance, setting of
families, diametrically opposed responses appeared.
conditions and time limits by which preserved gametes
Some urged and enacted policies that prohibited any
woman from undertaking surrogate gestation who had
The commissions contributed to ethical social
not previously delivered a child, on the principle that
policy development, in that they opened issues to
Ethical issues arising from the use of assisted reproductive technologies
public debate, either through their own processes or
means to address, though not necessarily to resolve
through generation of public discussion of their
to uniform satisfaction, a key ethical issue of where
conclusions, and sometimes both. They were
the burden of proof lies to preserve or change prevail-
respectful of those who made oral or written represen-
ing social policies. The evidence and policy implica-
tations to them, although at that time organized
tions arising from individuals’ access to ART services
religious institutions were better equipped to advance
and from operation of ART programmes are rarely
their views than bodies claiming to represent infertile
unequivocably favourable or unfavourable. It is
people, they beneficially added to public under-
uncertain, for instance, whether treatment that results
standing of the issues and response options raised
in an infertile couple having a new family of two or
by ART, and they attempted to justify their balancing
three prematurely born children that suffer respiratory
of the competing principles and pragmatic considera-
and/or neurological impairments is to be considered
tions that conditioned their conclusions and
successful or unsuccessful, or whether treatment that
recommendations. They had different levels of
provides an infertile couple with one or two healthy
success in having their recommendations enacted in
children following a multiple pregnancy that was
law, but tended to be well respected by medical and
“selectively reduced” by ending the lives in utero of
related professional associations whose members
several embryos or fetuses is to be celebrated or
deplored. When a country’s social policy is un-
The ethical character of these commissions was
accommodating of equivocal new technology, the
based more on the transparency and integrity of their
ethical question is whether potential users can claim
processes than on the substance of their conclusions
an ethical right to policy change to accommodate it,
and recommendations, many of which were conten-
so that opponents have to make the case to preserve
tious among ethical analysts and commentators.
the status quo, or whether the burden lies on
Many received information and opinions, and formed
supporters of the new technology to make the case
their own conclusions, before the present emphasis
for policy change. Similarly, when a government
on evidence-based medicine arose. In light of this
proposes a new law to restrict access to a newly
newer perspective, some of the information they were
developed service, the question is whether the
given and the scientific conclusions they reached
government has to make an ethical case (30), o r
might now appear questionable. Further, and perhaps
whether the ethical burden of resistance is on political
more significantly, they made no approach to advance
opponents; the policy is not ethical simply because a
or consider founding the social policies they explicitly
or implicitly adopted on empirical evidence. They
When the need for, or desirability of, policy reform
almost invariably accepted as true, for instance, that
is equivocal, and there is as much to be said against
children are better reared in legally married unions than
policy change as for, and vice versa, the question of
in unmarried unions, and that heterosexual parent-
whether supporters or opponents of policy change
hood provides a superior rearing environment to stable
bear the burden of making their case is decisive.
same-sex unions. Many uncritically accepted conven-
Neither case may be made persuasively, and the side
tional stereotypes of family life and functioning,
bearing the burden will fail to discharge it. Conserva-
without seeking or reviewing evidence, for instance,
tive or risk-averse forces will claim that a long-standing
of the incidence and nature of marriage breakdown
and adequate social policy should be changed only
and family dysfunction within their societies, and the
when advocates of innovation present a convincing
effects on children’s well-being. This deficit in these
argument in favour, and those of a reformist or socially
studies raises ethical concerns about the adequacy
experimental disposition will claim that prima facie
of this method of establishing, changing or declining
evidence of advantage from innovation should be
sufficient to propel policy reform, and that those resis-tant to reform bear the burden of establishing the case
The burden of proof
against it. In contrast, however, when a new practiceappears to threaten conventional values, such as
Commissions of enquiry often include members from
surrogate motherhood or human cloning, conserva-
the legal profession or judiciary, sometimes as their
tive forces want to speed restrictive provisions, and
leaders, and some indeed have been conducted within
reformists urge caution and time for balanced
law reform commissions (21,26). This may provide
reflection against precipitate prohibitions (31).
Both conservative and reformist preferences may
treated as objects, nor only as means to ends. As ends
be based on ethical principles, and often on variants
in themselves, individuals have inherent worth and
or counterpoints to the same principles. The principle
value, not simply the instrumental or utilitarian value
of beneficence may support reform to accommodate
ascribed to objects, which are valued only for what
the advantages attributable to a new technology, but
can be done with them. Accordingly, it is inconsistent
the duty to do no harm, nonmaleficence, may support
with their inherent worth that human gametes and
its rejection. Supporters of reform may claim that
embryos should become the subject of commercial
denying a policy that would accommodate the new
technology does harm to those it may benefit, and
This ethical reasoning is supported from a variety
that reform is required by the principle of justice, since
of extraneous perspectives. A religious view, adopted
the new but excluded practice is like one already
by the Roman Catholic Church in 1869, displacing
accommodated. However, opponents may identify a
earlier concepts of ensoulment that determined when
feature or consequence of the new practice that
the soul enters the body, is that human life begins at
renders it distinguishable. For instance, advocates of
conception or fertilization (34). This view requires that
cloning by embryo-splitting may claim that it only
an embryo be afforded the same respect and protec-
simulates natural or spontaneous identical twinning,
tion as a born person, although the application of this
and so should be allowed, while opponents may claim
view to sperm and ova appears more difficult to
that it accommodates multiplication by successive
establish (35). A view from philosophy and political
twinning of an embryo twinned in vitro and, unlike
science is that some interests, objects and functions,
natural twinning, allows identical twins to be gestated
such as motherhood, should not be amenable to market
and born years apart. A social policy compromise may
transactions because of the damage that would result
be to limit induced twinning to a single occasion, and
to human values, community and dignity. Margaret
require concurrent implantation of successfully
Radin, for example, condemns paid surrogate mother-
divided embryos. Ethics may provide no self-evident
hood as devaluing women in general, mothers in
or clear outcome on the merits of a particular case, but
particular, and children universally by making them
provide protagonists of different outcomes with the
“completely monetizable and fungible objects of
language and concepts of their advocacy.
exchange”‚ meaning that any one may be replaced byany other and has no individual value in itself, so
Commercialization of gametes/embryos
leading to “an inferior conception of human flourish-ing” (36).
The ethical argument against commercialization of
Ethical arguments against commercialization
gametes and embryos is not simply the pragmatic harmthis may do to the spirit and practice of altruism. Nor
Ethical arguments against commercialization include
is it the inducement payment affords sellers to conceal
reference to dangers of exploitation of vulnerable
and misrepresent reasons why the material they pro-
people, such as those who are impoverished, and to
pose to sell may be tainted and harmful to recipients,
the more abstract concept of human dignity (32). A
advanced in a modern classic text opposing paid
principal argument against allowing human gametes
donation of blood for transfusion (37), and indirectly
and embryos to be the subject of commercial or profit-
advocating the moral and practical superiority of (UK)
earning exchange stems from the ethical principle of
socialized medicine over (USA) market-directed health
respect for persons, which is sometimes considered
care. Rather, the argument is that commercialization
analogous to the concept of human dignity as applied
through commodification damages important ethical
in Europe. Neither gametes nor embryos are persons,
values in that it raises functional utility over inherent
but both may be considered potential persons and
human worth, invites competitive bidding for superior
what philosophers describe as “the argument from
over inferior products, in the case of gametes and
potential” (33) requires that they be treated with the
embryos‚ perhaps because of offensive distinctions
respect and dignity due to the persons they have the
in genetic pedigree and racial or ethnic properties, and
potential to become. Since abolition of slavery, the
imposes a monetary tariff on all means by which
concept advanced by the German secular philosopher
children are conceived and born. That is, a man’s
Immanuel Kant (1724–1804) has prevailed, that people,
loving act by which his wife conceives their child
and by implication potential people, should not be
becomes reduced to his transfer of sperm of a given
Ethical issues arising from the use of assisted reproductive technologies
market value, and her gestation becomes a service,
of donation with other payments for products and
even when unpaid, that is known to be commercially
services that are reputable and tolerated in materialistic
marketable at an employment rate per month or lesser
and capitalistic or market-based economies. They find
contradiction and even hypocrisy in social tolerance
This impoverishes the quality of human and family
and sometimes admiration of some forms of commerce
life, because it devalues and impersonalizes a
in the overcoming of infertility that accompanies
profound act of personal commitment and dedication.
condemnation of giving and receiving commercial
The social fracture in relationships is comparable to
rewards for supply of the gametes and embryos that
that done by a guest invited to a friend’s home for
may make treatment possible. For instance, medical
dinner who strips the invitation of its personal
practitioners earn professional fees or salaries for their
character by equating enjoyment of the company and
services (41), infertility clinics organize diagnosis and
the meal to a restaurant service, and expresses
treatment on a for-profit basis, particularly since
appreciation by placing the assessed money value on
publicly-funded health services tend not to cover
the table in cash. A more obvious analogy may be in
ART services adequately or at all, in some countries
equating reproduction to prostitution. This descrip-
sperm banks provide samples for payment, labora-
tion is now often redeemed or mitigated, acknowledg-
tories charge for testing gametes, genetic and other
ing the vulnerability and oppression that direct young
counsellors earn livelihoods by their availability and,
persons into this occupation, by being termed
for instance, drug companies and equipment manu-
“commercial sex work”‚ but its original description
facturers sell their products for care of infertile
implies shameful and immoral debasement, or sacrifice
patients. The demand or expectation that only those
who supply their own sperm, ova or embryos for the
This analogy contributes to another pragmatic
same purpose should be altruistic, appears unjust.
reason to oppose commerce in human gametes and
Even where the admonition of Richard Titmuss
embryos; that it would be liable to be exploitive of
against commercial purchase of blood for transfusion
those vulnerable through poverty who have no other
(37) is taken seriously, laws often allow payment for
means of earning. Gamete selling is more oppressive
whole blood or plasma donation, as an exception from
of women than is sperm selling of men, since ova
their general prohibition of commerce in human
recovery, perhaps following superovulation induced
tissues, on pragmatic grounds. The social need for an
by hormonal or other drug treatment, would be
adequate supply of transfusible blood and blood
considerably more physically invasive and un-
products overwhelms objections of principle to
comfortable or risk-laden. Similarly, experience shows
commercial transactions. The physical dangers to
that infertile couples may be induced to trade a number
which people are exposed from infertility are less than
of their cryopreserved embryos created in vitro in
those posed by loss of blood and by anaemia, but
exchange for a further treatment cycle, when they
where the claims of infertile patients to have children
cannot afford its financial costs. This payment in kind,
are respected, commercial incentives to donation,
in exchange for services rendered, would not be asked
where necessary, may be ethically tolerable. Accord-
or invited of couples that request further treatment on
ingly, the UK Human Fertilisation and Embryology
Authority (HFEA) has suspended its plan to prohibitpayment to sperm and ova donors of a modest fee and
Ethical arguments allowing commercialization
reasonable expenses (42). Allowance may serve theethical goal of beneficence, and the burden may fall
Few arguments urge commerce or trafficking in human
on those who argue that, on the contrary, commercial-
gametes or embryos as positively desirable in itself
ization violates the ethic of nonmaleficence, that is the
(38,39), and some who find payments defensible
ethic to do no harm, to make their case persuasively.
recognize that there is something unsavoury in
In utilitarian terms, they must show that the harm of
individuals selling their gametes (40). However, many
society enduring relievable childlessness, and
find that exchange for value may be tolerable, and
imposing it on those who seek to have children, is less
analogous to practices societies have already accept-
than the harms that would arise from commercial
ed. Invoking the ethical principle of justice, that like
transactions in human gametes and embryos.
cases be treated alike, they equate giving and
The case that would-be sellers might suppress
receiving commercial rewards for rendering the service
information that would expose their genetic material
and embryos as unsuitable for use is considerably
that ovum sales may involve women in medically
weakened where modern means of genetic diagnosis
unnecessary, invasive and risk-bearing treatments has
are available, since they make reliance on the
substance, but the procedures are the same for
proposed seller’s disclosure of personal and family
commercial as for altruistic donors, and although the
history less necessary. More persuasive may be the
latter may be willing so to serve only for family
claim that payment would induce poor people to
members and friends rather than for strangers, the
undertake what people of means refrain from doing,
exchange of money does not itself affect the nature
that is‚ to make their genetic material and embryos
of the procedures, and should not affect the care
available to strangers. The special emotional burden
offered by those who counsel or conduct them.
of donation of extra embryos created in infertility
The objection that commercialization of donation
treatment is that the gamete donors may remain
unfairly attracts poor people to serve as vendors, and
childless, while knowing or suspecting that a strange
unfairly privileges rich people as purchasers, may be
couple have borne and are rearing their child. The risk
factually correct. However, this does not distinguish
that impoverished people will become liable to
gamete and embryo sales from the attraction poor
exploitation arises from many sources. These include
people may feel to sell their labour in low-paying,
experience in tissue donation, for instance, when four
unpleasant or above-average risk employment, or from
poor Turkish workers were paid to fly to a London
the capacity of rich people to purchase superior
hospital for removal of kidneys for transplantation
consumer products and services, including private
into wealthy recipients, in documentation of eye and
health care. Where legal prohibitions exclude the
kidney sales in the Republic of Korea under recession
capacity of affluent people to purchase the products
(43), and in surrogate motherhood transactions when
and services they desire in their jurisdictions of
there are significant wealth differences between
residence, they are allowed to seek them elsewhere,
commissioning couples and gestational mothers,
including as “reproductive tourists”. In any event, the
raising concerns about “how such practices might fur-
unjust privileges available to people of means do not
ther oppress poor and disadvantaged women” (44).
provide ethical grounds to deny poor people the
Against this, however, it is argued that in order to
opportunity to obtain benefits as they perceive them.
sustain prohibitions of apparently exploitive practiceson ethical grounds, “we need better reasons than our
An ethical middle ground—regulation
own feelings of disgust” (45). “Protecting” willing,intellectually competent vendors of their gametes and
Even where gametes themselves cannot legally be sold
embryos against “exploitation” may disrespectfully
or purchased, donors often receive payments that may
deny them their ethical claim to autonomy, and hold
not be unlawful. Prohibition of commercial commodi-
them within a paternalistic confine that is itself an
fication of gametes has not prevented payments from
oppressive exercise of power over less powerful
being made to donors, not for their genetic material
members of society. They may consider such a sale
itself but for the service of making it available. That
to be the best option open to them, so that their posi-
is, they receive payment not in a commodity transac-
tion is worsened when the option is removed.
tion but under a service transaction. Men are not paid,
The argument that poor people cannot exercise
for instance, for the genetic properties or volume of
intelligent choice, such as the choice of a healthy,
their ejaculate, but for the service of offering its
fertile woman to donate ova or of a healthy, athletic
availability. In principle, they should receive the
man to undertake professional high-risk contact sport
scheduled payment even if their sperm are found on
such as boxing, is patronizing and insulting. The
analysis to be unsuitable for use in reproduction due,
argument that their choice is not freely made because
for instance, to a genetic deficiency or viral infection.
of the pressure of poverty scarcely provides an ethical
In the same way that health care professionals are
justification for further denying their choice. The claim
ethically entitled to charge conscionable fees for their
that their choice may not be adequately informed, for
services, gamete and embryo donors may claim that it
instance‚ because they have not been able to consider
is not unlawful or unethical that they should receive
or gain access to feasible options, provides a basis
payments that are proportionate to their inconven-
for affording them additional, realistic information or
ience in donation. For instance, in the UK, the Human
opportunities rather than denying them the choice of
Organ Transplants Act 1989 provides in section 1 (1)
acting on the information they possess. The objection
that a person commits an offence if (s)he “makes or
Ethical issues arising from the use of assisted reproductive technologies
receives any payment for the supply of, or for an offer
and an entirely free market is the ethical preference of
to supply, an organ”‚ but section 1 (3) states that
a regulated market. This is shown in the UK, where
“payment” means “payment in money or money’s
the HFEA monitors ART developments, licenses ART
worth but does not include any payment for defraying
centres according to their capacities of equipment and
or reimbursing … (b) any expenses or loss of earnings
personnel, enforces a Code of Practice, gathers
incurred by a person so far as reasonably and directly
relevant data and informs the public in general and
attributable to his supplying an organ from his body”
prospective users of services in particular of where
(46). Organs cannot be traded, but those supplying
they may receive treatment and how successfully
them can recover the reasonable costs of that service.
particular treatments, and treatment centres, work. The
Ethical concern that it is inconsistent to allow
HFEA monitors research initiatives, storage and
payment for the service of donation but not for the
disposal of embryos, and compliance with legal
donated product may be addressed, in part, by
requirements. The Authority also determines which
recognition that service costs are more measurable in
payments are acceptable and which are not, deciding
equitable market terms, and less open to the charge
in 1998, for instance, that it is tolerable for a patient’s
of people turning their bodies into “things”. in vitro fertilization (IVF) treatment to be subsidized
Rates for the supply of gametes and embryos
in return for the donation of some of her ova (50).
could be independently set or approved under
The HFEA’s observance of the law has also cast
regulations of an appropriate public or publicly
illumination on “reproductive tourism”. This is often
accountable agency. This would unlink buying from
discredited by association with sex tourism, the
selling, preclude private barter, and prevent wealthier
condemned practice of people, overwhelmingly men,
patients from outbidding less wealthy applicants for
going to usually poor foreign countries to have sexual
infertility treatment. Payments could be made by an
encounters with local residents that are unlawful in
independent agency rather than by, for instance, a for-
their own countries, such as with legal minors. In 1997,
profit clinic, and donations be allocated among clinics
the English Court of Appeal ruled that the HFEA
according to an equitable formula. This would address
correctly applied legislation of 1990 in denying a
an ethical objection to commodification of gametes
widow permission to be inseminated with sperm
and embryos, namely‚ that it unfairly privileges the
recovered without his consent from her comatose
wealthy through their superior means of purchase.
dying husband (51). The Court noted, however, that
Both banning commerce in gametes and embryos
the widow was entitled to seek lawful services in
and permitting their availability according to market
countries of the European Community that were
principles are ethically problematic. Bans risk exclusion
unlawful in the UK, and she subsequently was
of legitimate benefits, and injustice in light of what else
successfully inseminated in Belgium. Accordingly, so-
societies permit to be traded, and free operation of
called reproductive tourism need not be regarded only
market forces risks indignity and indefensible
as a devious way to avoid the restrictions of national
exploitation. In principle, markets may be believed to
laws, but may be an ethical means to achieve personal
solve problems of inadequate and surplus supply and,
reproductive goals compatibly with the different
for instance, of quality control, but these concepts
standards of one’s own country and of another where
seem inappropriate and offensive to common
services are lawfully available. Instead of using the
sentiment where human reproduction is concerned.
pejorative description of “reproductive tourism”‚ with
Even in the USA, where supply of health services is
its implications of flawed morality or leisure-time
widely believed best undertaken through private
triviality, it may pay ethical respect to those who seek
agencies, there are legal prohibitions of commerce in
to have children to employ a description such as
organs, children and, for instance, surrogate mother-
resort to “transnational services”.
hood services (47). The logical virtues of marketdiscipline are subordinated to moral repugnance (48). Conflicts of interest
Nevertheless, the ethics committee of the AmericanSociety for Reproductive Medicine has recommendedlimiting payment to the last few years’ “marketplace
Conflict in reality or in appearance
norm” of US$ 5000 per completed cycle for donatedova (49).
In ethics as in law, conflicts of interest clearly arise
Between the ethical hazards of a prohibited market
when those who induce others to depend on their
integrity and good faith place their own interests
instance, may pay staff members, who may also be
above those of such dependants. Accountability for
proprietors, inflated salaries, and function to cover
conflict of interest goes far beyond this, however,
their costs, which are boosted by paying such salaries.
because it also arises when those in whom others are
Although these clinics may accordingly be non-profit,
encouraged to trust are in a position to favour their
they may be sources of considerable personal
own interests, whether or not they actually succumb
to the temptation of self-interest. Practitioners in
Conflicts may appear in the options and advice
health care professions, on whose specialized
that practitioners offer patients on preservation and
knowledge and training lay people must necessarily
disposal of their gametes and embryos. If clinics make
depend for the services they feel they need, are almost
profits from storage, or storage fees contribute to pay
invariably enmeshed in multiple functions and
the costs of storage facilities, clinic personnel may
commitments that require an exercise of choice among
have an apparent interest to recommend or offer
options, some of which might appear more favourable
preservation, reinforced by the incentive this may give
to themselves than others, and some of which might
donors to remain in treatment programmes. It has been
appear less favourable to the interests of patients to
reported, for instance, that a facility in New York
whom they have conscientious duties. Conflict of
charges $ 500 for three months’ storage of embryos
interest arises not just from the actual prioritization
(53). As against this, however, patients’ compliance
of self-interest, but also from an appearance that self-
with requests or recommendations that patients
interest might be indulged at the cost of a reliant
should make surplus ova and/or embryos available for
patient. For many reproductive health care practi-
donation to other patients, may provide clinics with
tioners, in publicly funded facilities as well as in
access to scarce materials through which treatments
private, for-profit centres, conflict of interest created
can be offered to additional patients, and with
by the appearance of conflict of interest, is in-
incentives to super-ovulate women patients in ways
that may be contrary to their health interests and
Conflict is more obvious in some cases, of course,
reproductive options. The HFEA in the UK accepted
than in others. Professional fee-splitting is considered
transfer of ova for fees or as part-payment in kind for
conflictual because it risks dissipation of the practi-
infertility treatment late in 1998 (50), and has now
tioner’s allegiance to the patient (52). Practitioners
allowed similar donation of embryos (42). Practi-
who are also owners or financial shareholders in for-
tioners’ interests in preserving and employing
profit clinics, who advise clinic patients to take more
patients’ gametes and embryos in these ways are not
costly or prolonged treatments than appear indicated,
necessarily contrary to patients’ interests, but
are vulnerable to the suspicion of conflict. So equally,
opportunities for clinics’ and practitioners’ own
however, are practitioners on fixed salaries in publicly
advantage exist from which conflict may appear.
funded services, who advise patients whose carewould be costly of material resources and/or care-
The definition of “infertility” and “genetic risk”
givers’ time that their prospects of successfultreatment are poor, and that they should reconcile
Particular difficulty arises from different, legitimate
themselves to clinical failure and perhaps pursue an
definitions of what constitutes infertility, and from
alternative such as adoption. When practitioners
what outcomes of natural reproduction present
serving fee-paying patients with the same medical
prospective children with genetic risks. In Canada, for
characteristics advise them that further treatment is
instance, the Royal Commission on New Reproductive
worthwhile because it may succeed, it may appear that
Technologies, following the practice of the World
the former practitioners are unethically serving goals
Health Organization, conservatively defined infertility
of institutional economy, contrary to their patients’
as a failure to conceive following 24 months of normally
interests, that the latter practitioners are unethically
frequent unprotected sexual intercourse ( 2 9 ) ,
profiteering or serving futile extravagance, at their
whereas clinics often admit applicants on the basis of
12 months’ failure. Clearly, more couples are infertile
Practitioners therefore need not be employed in
by a 12-month test than by a 24-month test. This raises
for-profit clinics to fall under suspicion of being in a
the concern of whether clinics are being aggressively
conflict of interest. Private clinics that genuinely can
entrepreneurial and self-serving in admitting appli-
present themselves as non-profit institutions, for
cants of normal fertility or slight subfertility, claiming
Ethical issues arising from the use of assisted reproductive technologies
credit for pregnancies during the following 12 months
of their own values and biases, and to exercise the self-
that occurred or would have occurred naturally, or
restraint to suppress any tendencies to impose their
even applying procedures that obstruct pregnancies
own preferences that may be in conflict with those of
that would have happened without their interventions.
Clinics may justify a 12-month test, however, on
rational and compassionate grounds. Their clients, or
Resolution of conflicts of interest
patients, tend not to be young, newly married couples,but couples in which the female partners are approach-
In an idealized clinical setting for ART, conflicts of
ing, at or a little beyond so-described advanced
interest would be avoided. Although real settings are
maternal age, meaning about 35 years of age or above.
frequently far from ideal, the ethical principles of
They may be in second or later marriages, perhaps
beneficence, nonmaleficence and perhaps justice
having had children in earlier relationships but wanting
compel practitioners’ efforts to minimize the incidence
to have families in their new marriages. When
and extent of conflicts. For instance, clinicians should
women’s capacity to achieve pregnancy is in natural
not ask their patients to volunteer to be subjects of
decline, clinics are reluctant to require that they wait
research studies of which they are the principal
a further year or more to become eligible for treatment.
investigators, lest they unethically abuse their
Further, with a rising risk of abnormality in a later-
patients’ dependency on them for their own interests
conceived child, particularly Down syndrome, delay
(54). Similarly, clinicians should not accept or be
in access to ART may be clinically contraindicated.
required to be gatekeepers of departmental or other
Accordingly, clinics’ apparent haste in admitting
collective resources on which treatment of their
applicants to treatment on an assessment of their
individual patients must draw, lest they may favour
infertility may not be clinically suspect or unethical.
their patients to the disadvantage of colleagues’
Assessments of genetic or dysgenic risks to
patients, or violate their ethical duty of allegiance by
future children that may induce couples to forgo
sacrificing their patients’ interests to a perception of
natural reproduction and turn to gamete or embryo
departmental, institutional or other extraneous
donation, or to IVF with their own gametes and
priorities. As departmental or institutional gate-
preimplantation genetic diagnosis (PGD), may become
keepers, they are unethically compromised in
more refined with advances in genetic understanding.
discharge of duties owed to individual patients who
However, questions are likely to remain of calculations
rely on their disinterested judgment, clinical integrity
of genetic risk, how prospective children’s pre-
and capacity for supportive advocacy of their
dispositions or susceptibilities to illness or injury due
interests. In many legal systems, these ethical
to genetic inheritance are explained to prospective
responsibilities to patients are reinforced by the law.
parents, and what inherited conditions or abnormali-
Because conflicts of interest consist in appearance
ties render a child’s nonexistence preferable to its
as well as reality, they are frequently inescapable. They
existence, in its own interests, those of its prospective
may then be ethically resolved by due disclosure.
parents or those of others such as existing children
Disclosures should be to those at risk of suffering
of the family. A background concern is the qualifica-
disadvantage from a conflicted exercise of choice, or
tion a practitioner or counsellor has to undertake
at least to a superior officer whose duty is to ensure
genetic counselling of ill-informed and perhaps
ethical management of conflicts, and that those that
apprehensive applicants for ART. Considerable room
consist in appearance do not evolve to consist in
exists, by choice of language, emphasis, nuance,
reality too; that is, that an apparent conflict is confined
contrast or analogy, which may be deliberate or
to the superficial level of mere appearance. In the
unconscious, to control or influence patients’
doctor–patient setting, the doctor’s conflict should
decisions. Eugenic and aesthetic themes may infiltrate
in principle be disclosed to the patient. For instance,
discussions, on practitioners’ or counsellors’ initia-
doctors with financial interests in the profits of drug
tives. Their preferences for children of particular
companies whose products they are inclined to
stature, appearance and propensity can distort
prescribe, or for instance‚ in clinical laboratories to
prospective parents’ exercise of the choices that,
which they propose to refer their patients for the
ethically, they should be informed and empowered to
testing of their biological samples, should so inform
make. Practitioners and genetic counsellors must
the patients, and provide them with alternative drug
show that they can be relied upon to be self-conscious
or laboratory options in which they are disinterested.
Physicians’ interests in these regards are not
powerful parties not to benefit themselves at the cost
necessarily unethical. They may be based on a
of those they induce to depend on their superior
genuine conviction that these companies or labora-
tories provide superior products and services or, for
A particular conflict that may affect ART clinics
instance, on the conviction that, as interest-holders,
is how they report and advertise their treatment
the physicians can ensure maintenance or improve-
outcome data. Independent monitoring systems, such
ment of their products or standards. If these convic-
as in Sweden‚ may provide the public with reliable
tions are sincerely held, indeed, it may be unethical
data. Similarly, governmental agencies in, for instance,
for a physician to seek to avoid the appearance of
the UK and USA, require clinics to submit annual
conflict of interest by prescribing inferior products or
reports of their practices, including numbers of
referring patients to inferior services; disclosure may
patients and conditions treated, procedures under-
be the ethical ideal for patients’ informed choice.
taken and results. The Centers for Disease Control and
It has been seen that a conflict arises when a
Prevention (CDC) in the USA (57), and the HFEA in
person who wants therapeutic care from a clinician is
the UK (58,59) publish quite detailed aggregated
asked by that clinician, or by a colleague on his or her
annual data reports,and include warning that the data
behalf, to consider entering a study that the clinician
do not allow reliable comparisons among clinics, for
is proposing to conduct. The proposal requires that
instance‚ because they will have treated different
the person be clearly informed that treatment under
types of patients with different severities of reproduc-
the study is not intended primarily as therapy, and
tive disorders. Nevertheless, the news media have at
that, if the study design includes randomization
times publicized the data in the form of a table that
between an unproven intervention and a placebo, it
ranks clinics in order of their performance, or, as the
may include no proven medical treatment at all.
CDC report is entitled, their “success rates”.
Disclosure to the person seeking care is ethically
The conflict of interest, arising at both micro-
necessary, but not sufficient, because those asking
ethical and macroethical levels, is that clinics can
physicians for care often accept the so-called
influence their success rates by the choice of patients
“therapeutic fallacy” that the medical treatment they
they accept and how they treat them. They can achieve
are offered in research studies is intended for their
higher success rates by accepting only patients below
personal well-being. Accordingly, proposed investi-
certain age levels, who are more subfertile than
gators must also submit their study designs, including
infertile, and whose conditions afford greatest
details of how subjects are to be recruited and
prospects of successful treatment. Clinics that, as a
informed, to independent ethics review committees.
matter of social justice and commitment, or of research
These committees will address how adequately
interest to advance care, accept patients who have
prospective subjects are informed that the studies are
less promise of success and who are more difficult to
primarily intended to advance scientific knowledge
treat, are liable to appear lower in rankings of success.
rather than their personal therapy, and how capable
Clinics operated for profit, that promote their services
such subjects are to decline involvement in studies
by commercial advertisement, have an incentive to
and instead to obtain the therapy they seek.
boost their competitive status by screening out
A modern classic of unethically resolved conflict
applicants with poorer prospects of reproductive
of interest arose in the much-discussed legal case of
success, and admitting those of borderline infertility. Moore versus Regents of the University of California
Clinic success rates may be achieved at a loss of social
(55). A patient whose cells were found to have
unusually valuable genetic properties was asked to
A more immediate ethical concern is whether
provide additional tissues so that investigators,
clinics recommend more traditional infertility treat-
presenting themselves only as his therapists, could
ments before recourse to ART, even when their use
patent and trade in a cell line they biotechnologically
might compromise later ART, or whether ART will be
developed from them. The Supreme Court of California
first recommended when more traditional, less
dismissed his claims based on his property interest in
expensive procedures might succeed. Recommended
his cells or the cell-line, but allowed it to proceed for
care should be based on practitioners’ clinical
his lack of informed consent and the investigators’
judgement directed to each patient’s conscientiously
breach of the fiduciary duty they owed him. This is
assessed best interests. An incentive to achieve a
the way courts may reinforce the ethical duty of more
clinic’s financial success or an impressive publishable
Ethical issues arising from the use of assisted reproductive technologies
success rate may present a practitioner with an
ways of making babies: the case of egg donation.
unethical conflict of interest. Disclosure of the profit-
Bloomington, University of Indiana Press, 1996:89–91.
seeking status and preferred practice of clinics to
14. The New York State Task Force on Life and the Law. Assisted reproductive technologies: analysis and
regulatory authorities, and indirectly or directly to
recommendations for public policy. New York,
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desperate for reproductive success only limited means
15. Dickens BM. Reproductive technology and the ‘new’
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A Pilot Study on the Clinical Effectsof Forans Nutri-Gard® for relief ofGastric Ulcers in Horses R. van den Hoven, S. Wlaschitz, S.Leinker, C.Uray. Clinical Department of Small Animals and Horses, Clinic of InternalMedicine and Infectious Diseases, Veterinary University of Vienna, Veterinärplatz 1, A-1210 Vienna, Austria. Introduction Since 3 meter endoscopes have become routinely available
700 Olympic Plaza, Suite 850, Tyler, Texas, 75701 CERVICAL EPIDURAL INJECTION INFORMATION What is the epidural space? The covering over the nerve roots in the spine is cal ed the dura. The space surrounding this dura is the epidural space. Nerves travel through the epidural space before they travel down into your arms. The nerves leave the spine from smal nerve holes. Inflammatio