Carolyn McLeod

The stem cell debate continues: the buying and selling of eggs for research

Now that stem cell scientists are clamouring for human eggs for cloning-based stem cell research, there is vigorous debate about the ethics of paying women for their eggs. Generally speaking, some claim that women should be paid a fair wage for their reproductive labour or tissues, while others argue against the further commodification of reproductive labour or tissues and worry about voluntariness among potential egg providers. Siding mainly with those who believe that women should be financially compensated for providing eggs for research, the new stem cell guidelines of the International Society for Stem Cell Research (ISSCR) legitimise both reimbursement of direct expenses and financial compensation for many women who supply eggs for research. In this paper, the authors do not attempt to resolve the thorny issue of whether payment for eggs used in human embryonic stem cell research is ethically legitimate. Rather, they want to show specifically that the ISSCR recommended payment practices are deeply flawed and, more generally, that all payment schemes that aim to avoid undue inducement of women risk the global exploitation of economically disadvantaged women.

Choice in fertility preservation in girls and adolescent women with cancer.

With the cure rate for many pediatric malignancies now between 70% and 90%, infertility becomes an increasingly important issue. Strategies for preserving fertility in girls and adolescent women occur in two distinct phases. The first phase includes oophorectomy (usually unilateral) and cryopreservation of ovarian cortex slices or individual oocytes; ultrasound‐guided needle aspiration of oocytes, with or without in vitro maturation (IVM), followed by cryopreservation; and ovarian autografting to a distant site. The second phase occurs if the woman chooses to pursue pregnancy, and includes IVM of the oocytes, followed by in vitro fertilization (IVF) and transfer of any created embryos to the womans uterus (or to a surrogates uterus if the cancer patients uterus has been surgically removed or the endometrium destroyed by radiotherapy). For ovarian autografting, the woman would undergo menotropin ovarian stimulation and retrieval of matured oocytes (likely by laparotomy, but possibly by ultrasound‐guided needle aspiration if the ovary is positioned in an inaccessible location). The ethical challenges with each of these phases are many of fertility preservation and include issues of informed choice (consent or refusal). The lack of proven benefit with these strategies and the associated potential physical and psychological harms require careful attention to the key elements of informed choice, which include decisional capacity, disclosure, understanding and voluntariness, and to the benefits of in‐depth counseling to promote free and informed choice at a time that is emotionally difficult for the decision makers. Cancer 2006.

Justification for Conscience Exemptions in Health Care

Some bioethicists argue that conscientious objectors in health care should have to justify themselves, just as objectors in the military do. They should have to provide reasons that explain why they should be exempt from offering the services that they find offensive. There are two versions of this view in the literature, each giving different standards of justification. We show these views are each either too permissive (i.e. would result in problematic exemptions based on conscience) or too restrictive (i.e. would produce problematic denials of exemption). We then develop a middle ground position that we believe better combines respect for the conscience of healthcare professionals with concern for the duties that they owe to patients. Our claim, in short, is that insofar as objectors should have to justify themselves, they should have to do it according to the standard that we defend rather than according to the standards that others have developed.

Morally Justifying Oncofertility Research

Is research aimed at preserving the fertility of cancer patients morally justified? A satisfying answer to this question is missing from the literature on oncofertility. Rather than providing an answer, which is impossible to do in a short space, this chapter explains what it would take to provide such justification.

RICH DISCUSSION ABOUT REPRODUCTIVE AUTONOMY

Being able to decide whether or how to reproduce based on one’s own values is crucial to people’s well-being. In other words, having reproductive autonomy is crucial. The authors here discuss what it means to protect reproductive autonomy, what sort of policies will protect it and to what degree society ought to protect it. Many of the authors challenge common conceptions of reproductive autonomy that have misdirected genuine efforts to defend this freedom. The following are specific themes that appear in the work of multiple authors: Autonomy and Options: a common defence of new reproductive practices is that they increase people’s options and therefore increase their autonomy. As some of the authors emphasize, however, having more options does not necessarily mean having more autonomy. The act of expanding options can undermine autonomy by making choices ‘unproductively difficult’ (Kukla) or by making certain ‘choices’ irresistible (where the expanded options include an offer that the patient simply cannot refuse). It matters how health professionals present options and how socio-political norms influence our perception of them. It matters whether the available options cohere with patients’ values, and not simply how many options there are. The authors who deal with these issues directly are Kukla et al., Donchin, and Seavilleklein. They apply their insights about autonomy and options to the following issues respectively: ‘caesarean delivery upon maternal request’ (CDMR), conflicts over the disposition of frozen embryos, and prenatal screening. ‘Relational Autonomy’: during the past decade or more, feminists have promoted the idea of ‘relational autonomy’ as a replacement for autonomy traditionally understood. But people sometimes misinterpret ‘relational autonomy’. My hope is that this special issue will put an end to confusion surrounding the concept. A number of the contributors give clear articulations of relational autonomy (Goering, Donchin, Seavilleklein), and one even describes strong and weak versions of the concept (Donchin). These authors claim that we can only understand what it means to protect reproductive autonomy if we understand autonomy relationally: roughly, as a phenomenon that exists only in certain kinds of socio-political environments. What are matters of reproductive autonomy? When people think about reproductive autonomy, they typically focus on what happens before or during pregnancy. Kukla et al. encourage us to ‘find autonomy in birth,’ and think carefully about birthing options, especially CDMR. Goering introduces the concept of ‘postnatal reproductive autonomy’ and explains how reproductive health professionals, especially those in the NICU, can respect the autonomy of new parents. Practices that threaten or enhance reproductive autonomy: many of the authors emphasize that there is no simple answer to whether certain reproductive practices threaten or enhance reproductive autonomy. For example, Parks claims that whether ART is liberating or oppressive depends on how it is ‘taken up within’ a particular cultural context. She gives a radical feminist position on ART that is contextualist in nature. Harwood is skeptical about whether egg freezing ‘as ‘insurance’ against age-related infertility’ would truly promote women’s reproductive autonomy, although she does not deny that it could do so, under the right conditions. Goold & Savulescu write on the very same practice but are considerably less skeptical about it. They argue that women would benefit from what they call ‘social egg freezing’; in particular, women would enjoy more equality with men because of it. Limits on protecting reproductive autonomy: exercising reproductive autonomy can deprive other people of their reproductive autonomy or harm them more generally. Donchin focuses on the case of Natalie Evans, whose former partner withdrew his consent to the reproductive use of embryos created using his gametes and hers. Evans wanted the chance to be impregnated with these embryos, so she took him to court, but lost. To be clear, she wanted but was denied the chance to have any biological children, for immediately after the embryos were created, her ovaries were removed. Donchin speaks to those who believe that Evans’s reproductive autonomy deserved more consideration than her ex-partner’s and that the legal outcome of her case was unfair. DiSilvestro discusses whether bringing people into existence with the help of reproductive technologies or without the help of genetic tests can wrong them, even though they would not exist were it not for the very acts or omissions that are meant to have wronged them. DiSilvestro explains how some quite compelling attempts at solving this problem (the ‘non-identity problem’) do not succeed ultimately because they generate a new problem: Bioethics ISSN 0269-9702 (print); 1467-8519 (online) doi:10.1111/j.1467-8519.2008.00682.x Volume 23 Number 1 2009 pp ii–iii