Could Reproductive Liberty be Ethically Curtailed for Environmental Policy Reasons? or Why I Would Have Rejected Cristina Richie's Article on IVF

It's been a bit of a gale (as opposed to a bona fide storm) lately, following an article in the Journal of Medical Ethics by Cristina Richie, entitled "What would an environmentally sustainable reproductive technology industry look like?". It's not the question of a full hurricane, as in the infamous "after birth abortion" paper from 2012, but this rather raving rant is on the more aggressive end of the scale of reactions to Richie's piece. I dislike the language and the attitude expressed at the end of this article for simple reasons of decency and respect, but I also rather dislike Richie's article for more intellectual reasons. In fact, having read it, I have come to the conclusion that, had I been the JME reviewer for it, I would have recommended rejection.

Based on the undisputed fact that human reproduction carries with it a carbon footprint (assuming fixed per capita consumption levels related to population-size and -growth), Richie's paper argues about assisted reproductive technologies (ART), such as IVF, that...

The use of ART to produce more human-consumers in a time of climate change needs to be addressed.  Policymakers should ask carbon-emitting countries to change their habits to align with conservation. And though all areas of life – from transportation, to food, to planned technological obsolescence – must be analysed for ecological impact, the offerings of the medical industry, especially reproductive technologies, must be considered as well.

More specifically, she argues that access to ART should be restricted to "those who are not biologically infertile", meaning thereby to exclude, e.g., homosexual couples, single individuals and other "rainbow" family constellations. In particular, she claims, such restriction should befall publicly funded medical services of this kind. To season the stew somewhat, Richie is openly declared as belonging to "catholic theorlogical ethics", attached to an openly Catholic academic institution, the theology department of Boston College, a church well-known for its officially set hostile stance towards both ART in general and, in particular, technological facilitation of human reproduction in other social forms than within that of a married heterosexual couple.

Iain Brassington at the JME's blog has opposed the idea that Richie therefore should have declared a conflict of interest. He does however concur with several critics, some described here, that the attempted distinction between "biological" and other types of infertility is swampy territory. In fact, all infertility is always partly social, as it depends on a person or a group of persons being unsatisfied by existing alternatives to using ART, such as keep on trying the old "natural" way, attempt to adopt, or remain childless. A particularly tricky thing is that many times, individuals belonging to the group that Richie would presumably call "biologically" infertile, their infertility may very well be due to the fact that they prefer to keep to their couple relationship. Already here, had I been a reviewer of the paper, I would have unconditionally demanded revision. This is sloppy conceptual work of a sort a philosophy teacher slams A-level students for and it is given the job of providing substance to one of the article's main theses. I'm frankly surprised that reviewers and editors of a leading bioethics journal could let that one pass.

At the same time, Brassington insists in another comment that the general idea, which is the other thesis of the article, of subjecting human reproductive liberty and policies to the challenge of their impact on pressing environmental problems is not necessarily ill-conceived. Again, I agree, as I should do, having argued some 18 years back (an open access preprint is here) that global justice and health concerns may be reasons for people to avoid having children and rather adopt or otherwise assist existing children in need. As I argued in that context, however, Brassington observes that there seems to be no reason to restrict the environmental argument to the use of ART, but rather that if the argument bites, it points towards more general conclusions about the value of avoiding human procreation, e.g. via adoption or policies like the infamous Chinese 1-child restriction or other types of limitations.

Another comment that expands this particular line of criticism has emerged from Dominic Wilkinson, also on the JME blog, where he argues that Richie's argument is flawed to the core, due to its claim that ARTs are in some way extra environmentally problematic. Now, Richie herself does openly confess that this may very well not be so, but that she nevertheless chooses to restrict her paper to a thesis pertaining to ART. In other words, the main thesis of the article is entirely dependent on an ad hoc and arbitrary restriction of its thematic scope. Richie presents no argument justifying this restriction, but her article nevertheless is left to pursue a main claim pertaining to ART and only ART. This, given the level of ethical controversy around ARTs, is unjustified bias. Had Richie presented an argument in favour of the limitation of the scope it hadn't been so, but since she in fact claim herself that there's nothing special with ARTs, the article is clearly skewed in an unwarranted way. Therefore, had I been reviewer, I would have faulted the article on that ground, demanding a more general discussion of reproductive liberty in the face of environmental policy – alternatively, independent arguments for singling out ARTs as a specific target. This is a major flaw that the review or editorial process should have caught.

Together these two problems with the article point to a third one, namely that it aims to prove two intellectually independent main claims. This is asking for trouble, as everyone knows, but it is obvious why Richie wants to take the risk: without the combination, she wouldn't have been able to aim her shot specifically at the application of ART for the facilitation of reproduction within "alternative" families. Thus, Richie has an apparent (possibly religiously motivated) agenda to place a questioning of ART and specific applications of ART in a well-regarded scientific journal. Even if that doesn't amount to a conflict of interest, it undercuts the claim to intellectual honesty one would require of a researcher worthy of publication in the JME. Again, I'm surprised that this wasn't picked up in the JME review or editorial process.

Having said that, the general ethical issues arising out of the link between human reproduction and environmental concerns (of all kinds), are sure worthy of more reflection. In fact, this is something that I will be addressing with qualified colleagues at a panel convened by myself on Reproductive Public Health Ethics at the MANCEPT Workshops in Political Theory in just a few weeks.

Reproductive Public Health Ethics at MANCEPT 2014

Happy to be able to tell the world that a proposal headed by myself for a series of sessions at the increasingly popular and important MANCEPT Workshops in Political Theory conference has been accepted for this year's edition, September 8-10, 2014.

The proposal is on the theme of Reproductive Public Health Ethics, where a selected lineup of speakers from the Netherlands, Romania, Sweden and the UK will address different dimensions (biopolitics, bioethics, public health ethics, population ethics, environmental ethics) of ethics and value issues attached to reproductive policy. The presenters include, besides my humble self:

Gustaf Arrhenius
Richard Ashcroft
Becky Brown
Krister Bykvist
Daniela Cutas
Angus Dawson
Anca Gheaus
Kalle Grill
Marcel Verweij
Stephen Wilkinson

With a few possible additions to come. More on this as the exact program etc. is set and made public.

New book chapter available open access: The Best Interest of Children and the Basis of Family Policy: The issue of reproductive caring units

As some of you may recall, a little while ago, I flagged a forthcoming book called Families: Beyond the Nuclear Ideal (edited by daniela Cutas and Sarah Chan and published by Bloomsbury Academic in its Science, Ethics and Society series), where I have a chapter, together with my colleague Thomas Hartvigsson. What I was perhaps not entirely clear about is that, in fact, this chapter and – indeed! – the rest of the book is avaliable open access for reading and non-commercial sharing under a Creative Commons lisence, while the book can also be purchased as both hardcopy and e-book in the regular fashion. To me, a rather clever solution for trying to combine the commercial requirements of running a publishing business and still satisfy the very sound and strong arguments for having all sort of research material and academic output freely available for anyone.

Our chapter is called "The Best Interest of Children and the Basis of Family Policy: The issue of reproductive caring units" and deals with an issue that we introduce, thus:

The notion of the best interest of children figures prominently in family and reproductive policy discussions and there is a considerable body of empirical research attempting to connect the interests of children to how families and society interact. Most of this research regards the effects of societal responses to perceived problems in families, thus underlying policy on interventions such as adoption, foster care and temporary assumption of custodianship, but also support structures that help families cope with various challenges. However, reference to the best interest of children can also be applied to a more basic issue in family policy, namely that of what is to be considered a family in the first place. This issue does not raise any questions regarding the proper conditions for when society should intervene in or change the family context of a child. Rather, it is about what social configurations should be recognized as a potentially fitting context for children to enter into and (if all goes well) eventually develop into adulthood within. Any social configuration so recognized constitutes what we will call a reproductive caring unit (RCU). An RCU is a social configuration such that society's default institutional arrangements allow it to have (by sexual and artificial reproduction, adoption, and combinations of these), care for and/or guard children – the approved RCUs thereby being the basic ‘menu’ of what families with children there may be in society. Opinions on what should be allowed to be an RCU will frame any further discussion of the questions already mentioned, but also policies having further implications for, for example, the practices of adoption and reproductive technology, as well as regulation of custody in the event of separation or parental disagreement.

There is a communicative problem involved in talking about this issue in terms of the word ‘family’, however. Due to a combination of biological necessities, socio-economic and developmental circumstances, prejudice and custom, people around the world tend to associate this term with the presence of romantic or sexual relationships (between adults) and/or genetic links (between adults and children). However, the question indicated above does not necessarily imply such things to be in place in the case of a legitimate RCU. What should be awarded the standing of a family in this sense, then, may be something that many people find strange to call a family. At the same time, if you ask the question whether a single mother and her adopted child, or four adult siblings living together and caring for a foster child could constitute fitting social arrangements for children to enter and develop within, people would not (we presume) rule out this question as empty just because the word ‘family’ seems odd to apply to them. Rather, we suggest, social configurations within which children are raised are called ‘families’ as we tend to view them as legitimate RCUs. Thus, to the extent that there are reasons to allow RCUs not involving the ingredients of romantic/sexual relations or genetic linkage, this will be a reason to change linguistic practice.

The question we want to address, then, is about what is implied by arguments in terms of the best interest of children for the issue of what should be allowed to be a family in the sense of an RCU. This is a question not about particular cases, but about general institutional arrangements. Society needs policies as to what RCUs to allow and within these frames, any single initially legitimate RCU may be found unfitting for serving this purpose, just as in the case with dysfunctional ‘nuclear families’. Arguments about what is in the best interest of the concerned children in such cases can (and should) be brought to bear on this issue. However, as will be seen, these arguments involve quite different considerations compared to when assessments in terms of the best interest of children are applied to the issue of RCUs.

If you feel tempted by this, please just click on the chapter link, and read it in its entirety, as well as the other contributions to this book, by authors such as Adrienne Asch, David Gurnham, Paul D. Hastings, Kerry Lynn Macintosh, Julie McCandless, Melinda Roberts, Joanna E. Scheib, Mary Lyndon Shanley, Naura Irene Strassberg, and several others.

And if you like that, please consider buying the book, or at least liking its Facebook page, or in other ways contributing to spreading awareness of its availability. Thank you!

Families – Beyond the Nuclear Ideal...

...is the title of a book soon to be released by Bloomsbury Academic as part of its Science, Ethics and Innovation series, edited by Daniela Cutas and Sarah Chan, with one chapter contributed by myself and Thomas Hartvigsson (on how to apply the best interest of children standard to the issue of what sort of families to allow), plus others by, e.g., Adrienne Asch, Melinda Roberts, Kerry Lynn Macintosh and a number of other distinguished scholars in whose company I'm very proud to be.

 

In the words of the presentation by the editors, this book....

...examines, through a multidisciplinary lens, the possibilities offered by relationships and family forms that challenge the nuclear family ideal, and some of the arguments that recommend or disqualify these as legitimate units in our societies.

That children should be conceived naturally, born to and raised by their two young, heterosexual, married to each other, genetic parents; that this relationship between parents is also the ideal relationship between romantic or sexual partners; and that romance and sexual intimacy ought to be at the core of our closest personal relationships -- all these elements converge towards the ideal of the nuclear family.

The authors consider a range of relationship and family structures that depart from this ideal: polyamory and polygamy, single and polyparenting, parenting by gay and lesbian couples, as well as families created through current and prospective modes of assisted human reproduction such as surrogate motherhood, donor insemination, and reproductive cloning.

And the full table of contents runs like this:

Chapter 1: Daniela Cutas and Sarah Chan, Introduction: Perspectives on Private and Family Life
Chapter 2: Julie McCandless, The Role of Sexual Partnership in UK Family Law: the Case of Legal Parenthood

Chapter 3: Mianna Lotz, The Two-Parent Limitation in ART Parentage Law: Old Fashioned Law for New-Fashioned Families
Chapter 4: Christian Munthe and Thomas Hartvigsson, The Best Interest of Children and the Basis of Family Policy: The Issue of Reproductive Caring Units
Chapter 5: Joanna Scheib and Paul Hastings, Donor-conceived Children Raised by Lesbian Couples: Socialization and Development in a New Form of Planned Family
Chapter 6: David Gurnham, Donor-conception as a ‘Dangerous Supplement’ to the Nuclear Family: What can we learn from parents’ stories?
Chapter 7: Susanna Graham, Choosing Single Motherhood? Single Women Negotiating the Nuclear Family Ideal
Chapter 8: Mary Shanley and Sujatha Jesudason, Surrogacy: Reinscribing or Pluralizing Understandings of Family?
Chapter 9: Adrienne Asch, Licensing Parents: Regulating Assisted Reproduction
Chapter 10: Simon Căbulea May, Liberal Feminism and the Ethics of Polygamy
Chapter 11: Maura Irene Strassberg, Distinguishing Polygamy and Polyamory Under the Criminal Law
Chapter 12: Dossie Easton, Sex and Relationships: reflections on living outside the box  

Chapter 13: Kerry Lynn Macintosh, Human Cloning and the Family in the New Millenium  

Chapter 14: Melinda Roberts, Moral and Legal Constraints on Human Reproductive Cloning

 

You can follow the book on its Facebook page to receive notification of publication, ordering opportunities, and so on.

More on the Ethics of Uterus Transplantation

Here are two posts that continues to ad takes on the recent news of advanced plans to conduct uterus transplantation at the Sahlgrenska University Hospital in my town.

one at the Oxford Practical Ethics blog by Charles Foster that generated a bit of a discussion (with myself as one of several participants), and

another, very fresh, at the Journal of Medical Ethics blog by Iain Brassington.

In short, Foster takes the discussion to a meta-level, while Brassington wriggles it back to the floor of the clinic.

Enjoy!

Uterus Transplantation: Clinical Trial Planned in One Year from Now

In October last year, I reported about the plans of a Swedish team of medical researchers, based in my city, to conduct uterus transplantation. At the time, they had just initiated the final stage of animal experiments on large primates, to validate safety and effectiveness of the procedure.

Today, BBC aired an interview with a woman who has agreed to donate her uterus to her own daughter, who suffers from the Mayer Rokitansky Kuster Hauser syndrome (MRKH) – one of the conditions targeted by this new procedure. The news is also presented in The Telegraph, and in Swedish media (here, here). The trial is planned to take place about one year from now at the Sahlgrenska University Hospital in Gothenburg (my home town).

I am unsure about how far the primate trials have proceeded, but before any trial is initiated, the responsible surgeon – Mats Brännström – will, by Swedish law, have to secure ethical permission. There are several potential risk factors with the actual surgery (as acknowledged by Brännström), and also uncertainty as to how the chances of establishing a pregnancy may be affected by the various parts of the procedure, such as drugs taken to prevent the new uterus to be attacked by the recipient's immune system. Presumably, the fact that the donor is a close relative of the recipient is a part of the actions taken to reduce this last risk factor (since less of the drugs will be needed than if the donor had been genetically more distant from the recipient).

My own guess is that the team will have to present very strong evidence to the Ethics Review Board, since the procedure is not life-saving. For other ethical considerations, see my earlier post!

Uterus transplantation: ethics and pragmatics

Today, Swedish media report (here, here, here, here, here, just to name a few) on plans of a group of researchers at the Sahlgrenska University Hospital and the University of Gothenburg, to conduct the world's first ever transplantation of a human uterus. After successful experiments on rats (and a number of other animals), the team – headed by professor Mats Brännström at the unit of obsterics and gynecology – is now working on baboons in order to secure a basis of results that could motivate a move into the actual human clinical trials. The research is held out as a prospect for certain infertile couples and an alternative to surrogacy, adoption and similar methods currently used to overcome the problems faced by this group of people.

Needless to say, the research raises a number of ethical questions, something at least partly recognized by the researchers when they write in their online presentation of the research: "We think that it is necessary to look closely into these aspects of uterine transplantation before it can be developed and used in the human". This alludes primarily to the need to secure the efficacy and safety of the method before attempting to use it clinically, which is, of course, a priority. However, already this obvious issue will undoubtedly raise more subtle issues.

One of these connect to the rather sad track record of reproductive medicine when it comes to moderating its drive towards applying new ideas and technologies in light of safety and others ethics considerations. Sterilization policies and the early history of IVF continues to be a moral backpack that needs to be carried by contemporary researchers and clinicians in reproductive medicine (just as in genetics). The critical outlook from a feminist perspective by such commentators as Christine Overall and Gene Corea, to name two of the more prominent, have pointed out the dangers of reproductive technology to transform women into mere means for the production of offspring in a social context dominated by mechanisms and cultural patterns aiming at a patriarchal control of reproduction. While the influence of this tendency is hard to argue with (the fate of women have indeed been a secondary consideration in many cases of reproductive technological advances), at the same time, there are also sides to the developments that arguably are to the benefit of women as well as other groups that are or have been systematically marginalised. In as much as individuals, couples and whatever other groupings that wish to transform themselves into a reproducing family are able to overcome oppressive socio-cultural structures, the technological advances do produce new options. The threat of these options being unduly pressed on people (especially women) or used for oppressive purposes in other ways has to be recognized, of course, but you would need to be a very hard-nosed structuralist indeed to claim that the individual can never utilize available options to their own advantage. In fact, one of the main points of the high priestess of queer theory, Judith Butler, seems to be that such utilization is one of the primary roads towards overthrowing oppressive sexual structures – social, cultural and conceptual.

Having said that, the idea behind the uterus transplantation project seems, however, to present a bit of a problem from the just outlined perspective. One of the prime rationales behind the research held out in today's press reports is that the options currently faced by women facing the sort of problems that may actualize a uterus transplantation – adoption or surrogacy – are hard, burdensome or impossible to access. In Sweden, surrogacy is not legally available (except, of course off shore) and adoption is a difficult, lengthy and costly process. In other nations, surrogacy may be available, making it possible for Swedish women with the personal and financial resources required to go there for such arrangements, but not for less fortunate women. In light of this, the researchers claim, uterus transplantation carries a liberating prospect by making available a procedure that may facilitate having children for those of these women who so wish. But what this means seems to be that the situation is exactly of the sort that the feminist critics of reproductive technology have pointed out as problematic. Women who suffer the sort of physical dysfunction we are talking about will not be in a position to freely choose uterus transplantation as the preferred solution to their problem compared to other feasible options. Rather, their freedom of choice will be heavily constrained by socio-cultural-economic factors. Put in another way: the source of the problem to be solved by uterus transplantation seems to be primarily about the oppressive effects of current legislation, economic arrangements and cultural preconceptions. It could, apparently, be solved just as well by making surrogacy and adoption more available.

But of course, such changes may not in fact be forthcoming. The rationale of the researchers may then be turned into one of simple pragmatics. They can say: "we would simply love it if the socio-economic patterns oppressing our patients were to change for the better, but until then we have reason to work on our research". The critic following the sort of lines sketched above would then have to resort to the structuralist mantra of negative feedback loops; the dogma that whatever is done to help people in oppressive circumstances will sustain the oppression. Besides being a corner impossible to get out of, such an argument would need the support of convincing empirical evidence in the area of reproduction, e.g., regarding contraceptives, legal abortion, freedom to marry and divorce, etcetera.

Thus, ethics in this area teaches us to be mindful about the effects of social structures and cultural contexts, so that we are not trapped by blind spots and prejudgments. But the presence of such structures and contexts does not by itself constitute a knock-down argument. History can teach us a great deal about that, as can ethics research and experience from other cases of reproductive technology. The worry I am nurturing rather concerns if the researchers involved have secured  access to the resources and competence needed for living up to that, which takes me back to where I began; the evaluation of risks and benefits when (a) deciding whether or not to take the step over to clinical trial, (b) conducting such a trial, (c) deciding on basis of the trial whether or not to offer to the procedure, on what conditions and to whom. And, of course, in light of what has been said, the overarching evaluation in terms of fairness and cost-benefit, whether this is where the resources for liberating and helping the group of patients concerned are best spent. Once a procedure is (ethically and medically) ready for clinical use (i.e. if not the results of the trials are too poor), this last issue will undoubtedly step forward as a primary one in critical discussion.