The Ethics of Assisted Reproductive Technologies

By OBOS Infertility Contributors | October 15, 2011

Assisted reproduction can raise complicated ethical challenges for the individuals involved, health care professionals, and the greater society. Infertility treatments today create new definitions of parents and children and require a rethinking of the conventional notions of family. For families facing infertility, decisions about family building become complex.

One ethical dilemma associated with ARTs involves the politics of embryos and what to do with unused embryos. Many couples fertilize as many eggs as they can during their treatments and freeze any remaining embryos for later use. It’s estimated that about 600,000 cryopreserved embryos are being stored in fertility clinics across the United States.

Many are eventually used for family building, but many remain unused, and often couples are ill equipped to make a decision about what to do with their embryos once their families are complete. Some just stop paying the storage fees or lose contact with the clinics.

For both ethical and legal reasons, clinics are reluctant to dispose of embryos without a couple’s consent. Couples who want to donate them to research are confused by varying laws and restrictions stymieing their ability to donate.

Very few couples opt to donate their embryos to other couples due to lack of education about the option and ethical and moral concerns about giving one’s genetically related embryos to an unknown couple. Moreover, many couples have a hard time coming to terms with permanently disposing of them, even through a compassionate transfer in which the remaining embryos are thawed and placed into the vagina at a time when conception is not possible.

It’s important for couples to think about what they will do with their remaining embryos before they undergo fertility treatments and begin to create embryos. If not, they may struggle with the uncertainty about what to do with them for years or even decades. Further conflict occurs in situations of divorce or death. Laws are not consistent from state to state about who is ultimately responsible for embryos and what can be done with them. Given the length of time some embryos have been cryopreserved, some people have even included them in their wills, further delaying any conclusion.

Third-party reproduction, in which another person enters into the babymaking mix, also involves risks and raises many important ethical concerns. Though the FDA ensures the overall safety of the gametes, there is much more involved with such treatments than the passing of genetic material from one person to another.

There is no consensus about how to appropriately and ethically recruit donors and surrogates or how to eliminate the risk of coercion or exploitation. Since money (often large amounts) is exchanged, commodification of reproduction is suggested.

Furthermore, there is no guarantee that donors and surrogates fully understand the risks involved or are able to provide informed consent, especially given the lack of standards for education and screening. Further complicating matters, the intended parents pay for all costs involved, creating a great deal of pressure for donor programs and surrogacy agencies to quickly find matches for their clients—the intended families—and creating a conflict of interest in terms of whose interests are being protected. Even though recommendations exist as to how many times one can donate or be a surrogate and under what conditions, they aren’t enforced.

Some women’s health activists have concerns about the health risks to egg donors from using the drugs that stimulate ovulation. There is a lack of long-term safety data and too little research on the serious, occasionally irreversible problems experienced by some women using the drugs. Some people fear that the risks of egg donation have been underplayed and feel that regulations are needed to better ensure that the long-term consequences of donation are better understood. Several advocacy groups are calling for a national egg donor registry to better track the effects of these drugs. For more information, see Egg Donors Create Support Group for Women and Push for More Safety Data.

In addition, there has been little research on what happens to donors, surrogates, intended families, and children after donation or birth—physically or emotionally. People who have built their families through collaborative reproduction are not followed. There is also no method for donors to contact families they helped to build or vice versa later on.

This is especially concerning if a medical need arises or information about their own personal or family health history changes. In fact, most sperm and egg donors never know if their donation even resulted in a pregnancy. We need to know more about what happens down the road for donors, surrogates, recipient parents, and their children so we can minimize any negative consequences, including unintentional ones.

Treating infertility in the United States has become an extremely technical, competitive $3.5-billion-a-year business. Physicians providing treatment are often also business owners aware of profit margins. Many fertility clinics feel pressure to produce statistics that show potential patients the highest possible pregnancy and birth rates. This sometimes affects their choices regarding treatments.

Likewise, fertility doctors struggle with trying to appease patients (rather than lose them to another clinic) who want to proceed with certain treatments when the chances of a good outcome are remote and other more appropriate options such as using donor eggs, surrogacy, adoption, or stopping treatment do not appear to be acceptable.

The business side of infertility treatments also restricts access to care for many families who don’t have the necessary financial resources, since infertility treatment is not typically covered by insurance. Many people seek out other options, such as traveling to other countries for cheaper treatment. Several countries have severely restricted infertility treatments or require long waiting times, causing many families to travel elsewhere for treatments.

Some people who travel to other countries are able to get good state-of-the-art care by well-trained physicians at an affordable price. Others find themselves in situations that may be unethical or unsafe, particularly with regard to egg donation or surrogacy, where very poor and uneducated women may be exploited for their reproductive potential. (For more information, see Cross-Border Surrogacy: How OBOS is Advancing Public Discourse and Action.) Unfortunately, guidelines, standards, and sources of unbiased information protecting donors, surrogates, and families struggling to have a baby are inadequate.

As technologies continue to proliferate, ethical and social challenges multiply, with complex questions of justice, rights, and conflicting principles continually raised. As a society, we are long overdue to discuss these issues and to guard against leaving them solely in the province of researchers and biotechnology entrepreneurs. We also need to devote resources and energies to identify and remove the environmental and physical causes of infertility. Prevention, education, and increased access to appropriate and cost-effective fertility care, including insurance coverage, are also imperative so that more families throughout the world are able to safely have children when they are ready.