You don't need to be signed in to read BMJ Blogs, but you can register here to receive updates about other BMJ products and services via our Group site.

Reproduction

Gaia Doesn’t Care where your Baby Comes From

25 Jul, 14 | by Iain Brassington

Guest Post by Dominic Wilkinson, Associate Editor, Journal of Medical Ethics

In a provocative paper published today in the Journal of Medical Ethics, US theologian Cristina Richie argues that the carbon cost and environmental impact of population growth in the West should lead to restrictions on artificial reproduction.  She points to the substantial carbon emissions that result from birth in developed countries like North America.  Seven percent of the world’s population contribute fifty percent of the world’s CO2 emissions, and children born by in vitro fertilization are likely to be in this seven percent.  Richie argues in favour of a carbon cap on artificial reproduction and argues that IVF should not be funded for women who are “biologically fertile”.

Richie is correct to point to the enormous carbon cost of additional human population. One of the most significant ways that individuals in Western countries can reduce global carbon emissions is by having fewer children. However, her focus on artificial reproduction and on the “biologically fertile” is not justified.

Richie ignores questions about the moral implications of climate change and climate cost for natural reproduction.  She sets to one side “the larger realm of sexual ethics and procreation”.  Yet there are two reasons for thinking that this is a mistake.  First, as Richie notes, “Reproduction-related CO2 is primarily due to choices of those who have children naturally: a huge majority of all births.”  Only 2% of all children born in the UK are conceived by IVF.[1]  Therefore interventions to reduce the number of children naturally conceived will potentially have a fifty fold higher impact on carbon emissions.  Secondly, it is profoundly unjust to apply restrictions to reproduction only on those who are unable to conceive by natural means.  It could be justified to limit the reproductive choices of women because of concern for the environment.  However, if this were justified, it would be equally justified to try to limit the reproduction of the naturally fertile and the naturally infertile.  It is ad hoc and unfair to confine our attention to those who must reproduce artificially.

Second, Richie proposes that public funding for IVF be confined to those who are “biologically infertile”, excluding same sex couples and single women.  However, she provides no reason at all for restricting the availability of IVF for these women.  Put simply, the carbon cost of artificial reproduction is exactly the same for a woman who is infertile because of endometriosis or polycystic ovary syndrome or because she does not have a male partner.  The only possible reason for making a distinction between biologically infertile and biologically fertile women is because Richie believes that lesbian and single women are less deserving of public funding because of their lifestyle choices.  However, that argument, as problematic and contentious as it is, is completely independent of the question of environmental impact.  The carbon cost of children born to gay couples is likely to be exactly the same as the carbon cost of children born to women with endometriosis.

The carbon cost of additional births might well be sufficiently important for the state to justify limiting reproductive freedom.  However, if the state is going to interfere in couples’ decisions about whether to have children or the number of children that they have, it should do so fairly and equally.  Carbon caps should be applied equally to those who conceive naturally and those who require artificial reproductive treatment.  They should not be used as a way to discriminate against those who are single or gay, or have some other ‘undesirable’ characteristic.

 

[1] http://www.hfea.gov.uk/ivf-figures-2006.html#1284

ARTs in a Warming World

25 Jul, 14 | by Iain Brassington

There are some people who disagree, but we can take some things as read: there is such a thing as global climate change, it is at least substantially anthropogenic, and there are moral reasons to try to minimise it.

With that in mind, how should we think about reproductive technologies?  These are techniques whose intent is to create humans, and – presumably – those humans will have an environmental impact.  This is a question that Christina Richie confronts in her paper in the JME:

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.

One of her suggestions is of carbon-capping for the fertility industry; she’s more reluctant to suggest a moratorium on the use of ARTs.  But she does suggest thinking quite seriously about who should get access to fertility treatment.  After all, she points out, fertility treatment is unlike other medical treatments in a number of ways.  Not the least of these is that someone whose life is saved by medicine will go on to have a carbon footprint bigger than it might have been – but that’s not the intention.  The whole point of fertility treatment is to create new humans, though – and therefore the treatment has not just a footprint, but a long-lasting carbon legacy.

I wonder, actually, whether the argument could be radicalised. more…

Are FIGO’s Regulations Risking the Lives of Pregnant Women?

10 Jul, 14 | by Iain Brassington

Guest post by Douwe Verkuyl

The International Federation of Gynecology and Obstetrics (FIGO) Committee for the Ethical Aspects of Human Reproduction and Women’s Health believes that there is never an indication for a tubal occlusion (TO) to be performed at the time of caesarean section or following a vaginal delivery in cases where this sterilisation has not been discussed with the woman in an earlier phase of her pregnancy.  This applies even if there is a uterus rupture.

But what if a mother of 5 children, living in rural Africa near a Catholic clinic, unexpectedly needs referral to a government hospital because of arrested labour, and faces a journey of at least 4 hours over a dirt road?  Does the Committee’s recommendation against belated TO counselling still apply if referring establishments have deliberately ignored its advice to counsel pregnant women early in pregnancy about the option of a concurrent sterilisation in the event that a caesarean section is needed?  Catholic institutions – which are often the only health facility for miles around – not only ignore this advice, but also fail to assist a woman with “sinful” modern contraception after she has returned with a scarred uterus.  In many Western, developed countries, Catholic contraception doctrines are mostly inconvenient, guilt-provoking and expensive.  In rural Africa, Latin America and the Philippines, they often kill.

Imagine a 37-year-old woman in labour in a well-equipped and staffed Doctors Without Borders (DWB) emergency hospital which happened to be located near her home.  She has previously given birth, with some difficulty, six times at home, and now there is a full civil war.  The doctors detect foetal distress.  They think there might be a 10%-30% chance her child will be damaged or die before it is born.  On the other hand, with the uncertain political situation – consider that on 17 June a DWB hospital was bombed in Sudan – and poor infrastructure, it might be the case that her chance of dying from a uterine scar during a subsequent labour is around 30%, and the probability that she has continuous access to reliable reversible contraception for the next 13 years is zero.  If she would choose to have a TO with a caesarean section that would solve the quandary.  Is it really unethical to ask her, or unethical not to give her that choice?

Read the full paper in the latest edition of the JME here.

Their Poor Little Heads might Explode

1 Jun, 14 | by Iain Brassington

There’s a nice little piece by Martin Robbins in this week’s Guardian in which he talks about the fact that women seem to be less supportive of abortion than men.  That does seem counterintuitive, given that… well, given the obvious physiological facts and the relative burden of risks related to pregnancy.  So there’s an interesting little anthropological puzzle here; and he suggests a number of factors that might explain the phenomenon. For example, there’s some research that finds that women are more likely than men to agree that life begins at conception – though, as he points out, while that might help explain the different views of termination, we’d still need to know why more women think that to begin with. Another potential explanation is that men like the idea of not having to do the right thing by their pregnant partners by paying child-support or, if you’re reading this in the 1950s, marrying them: abortion gives a way out of that.  But – and Robbins doesn’t mention this – that again presupposes keeping the baby as the default position to which people are looking for an alternative.  We could also talk about social pressure, and the way that women are still expected to be mothers, and how that feeds into attitudes.  In fact, we could talk about a lot of things:

So which is it? Internalised sexism, men’s liberation, fundamentally different ideas about the point at which life begins, or something else entirely? I doubt only one factor is at work, but it seems that we lack a definitive answer. And that’s a shame, because in the ongoing battle of ideas it seems like a very important question to ask.

I suspect some will deride his “we need to do more research” conclusion, but it seems eminently sensible to say that, faced with a quirk of attitudes, a full explanation would be at least aesthetically satisfying, even if not especially urgent.  He also provides lots of useful links.

Over at the CMF blog, Philippa Taylor’s suggestion – which also has lots of useful links – is a little different. more…

Oh, and while we’re talking about media hype…

1 Apr, 14 | by Iain Brassington

… there’s this, from last week’s Independent:

Thousands of unborn foetuses incinerated to heat UK hospitals

The bodies of more than 15,000 unborn foetuses have been incinerated in the UK, an investigation has found, with some treated as “clinical waste” and others burned to heat hospitals.

The practice was carried out by 27 NHS trusts, with at least 15,500 bodies burned over the last two years alone.

Ten of those trusts admitted to burning more than 1,000 sets of remains along with other hospital rubbish, while two said they were incinerated in “waste-to-energy” furnaces that generate energy used to power and heat hospitals.

Gasp!  One kind of human tissue is disposed of in the same way as other kinds of human tissue!

From the tone of the reporting, one would only be mildly surprised to find people employed to encourage abortions in order that hospitals can save money on fuel.

Except that that’s nonsense.  If clinical waste is incinerated in waste-to-heat plants, it doesn’t follow that it’s being incinerated to provide heating; rather, it’s that the heat from the incinerator is captured and put to use, rather than being wasted.  For sure, the physics is the same; but the emphasis makes a heck of a difference.  (And, as PZ points out, for abortus* to be an effective fuel would require them to be “the most energy-dense substance in the world”.)  So what we actually have is a situation in which an abortus is incinerated.

And the problem with that is…?

Um…

Well, I’m sure there must be one, because health minister Dan Poulter is reported as describing the practice as “totally unacceptable”, and Poulter is an honourable man.

Actually, there is a few things that might strike us as questionable – though as we’ll see, the fact that something prompts a question doesn’t really tell us much, since some questions can be answered easily.   more…

Multiplex Parenting: in vitro Gametogenesis and the Generations to Come

24 Mar, 14 | by BMJ

Guest Post by César Palacios-González, John Harris and Giuseppe Testa; for the full paper, click here.

Recent biotechnology breakthroughs suggest that functional human gametes could soon be created in vitro.  While the ethical debate on the uses of in vitro generated gametes (IVG) was originally constrained by the fact that they could be derived only from embryonic stem cell lines, the advent of induced Pluripotent Stem Cells (hiPSC) creates the possibility that somatic cells may be used to generate gametes.  This means that in the future it might be possible to generate human sperm and oocytes from male cells, and oocytes from female cells.  (So far it has not been possible to derive sperm from female cells.)

Among the different applications that have been explored in the academic literature, like the creation of embryos for genetic research and what has been called “in vitro eugenics”, we think that the most dramatic application of IVG will be in the field of human reproduction.  In a recent article in the Journal of Medical Ethics, Robert Sparrow rightly notices that IVG could allow post-puberty males who are unable to produce viable sperm, women who have undergone premature menopause, and those who have lost their gonads due to injury or had them removed in the course of cancer treatment to have genetically related kin.  To this list we add (and explore in our paper) a fourth use that has been overlooked until now: that IVG would allow the reparation of some of the harms done to people by means of biological involuntary sterilization. more…

Sex-Selection and Abortion: Is there a Problem?

17 Jan, 14 | by Iain Brassington

This is just a quick post, and it’s mainly to draw your attention to a couple of other posts worth reading elsewhere.

A little background: there’s been a minor fuss* in the media over the last few days concerning sex-specific abortion**, after The Independent reported that

[t]he practice of sex-selective abortion is now so commonplace that it has affected the natural 50:50 balance of boys to girls within some immigrant groups and has led to the “disappearance” of between 1,400 and 4,700 females from the national census records of England and Wales, we can reveal.

Now, there’s something a bit fishy about the article even on its own terms: alarm bells should be got ringing by this:

[O]ur deeper statistical analysis of data from the 2011 National Census has shown widespread discrepancies in the sex ratio of children in some immigrant families, which can only be easily explained by women choosing to abort female foetuses in the hope of becoming quickly pregnant again with a boy.

After all, it does seem to reduce to a claim along the lines that “I can’t think of a better explanation than e for phenomenon p, therefore e obtains” – but that tells us far more about the limits of the speaker’s imagination than about the state of the world.  Besides, while there are good reasons to favour the most simple explanation of p, one ought to keep a distinction between the simple and the simplistic.  Bluntly, an easy explanation isn’t any more likely to be true by dint of being easy.  E=mc2 is simple once you’ve derived it, but its derivation isn’t easy.

But how reliable is the Indy‘s analysis anyway?  I’ve not gone through the data myself, but Unity has, and has a couple of really good posts: the first is here, and the followup is here.

They’re very worth the read – but I recommend that you make yourself a good cup of tea before starting them.  They’re looooooong.  I’d be interested to know what others think, though.

 

UPDATE: There’s even more.  I think Unity’s enjoying himself with this.

 

* Minor in the sense that it’s been eclipsed by things like Oscar nominations.

** Here’s Christina Odone, for example, blaming it all on feminism.  Surprised?  You could knock me down with a bulldozer.

Identity and IVF

11 Jan, 14 | by Iain Brassington

It’s good to see that Stephen Latham is blogging again after a short hiatus; and he’s come back with a really thought-provoking post on IVF and problems of identity.

The background is this: apparently, there is evidence that children conceived by IVF are at an elevated risk of health problems compared to kids conceived naturally:

Compared to spontaneously-conceived singletons, singletons from assisted conception were almost twice as likely to be stillborn, more than twice as likely to be pre-term, almost three times as likely to have very low birth weight, and twice as likely to die within the first four weeks after birth. Outcomes varied by type of assisted conception. Very low and low birth weight, very preterm and preterm birth, and neonatal death were “markedly” more common in births from IVF and, to a lesser degree, in births from ICSI. Use of frozen embryos elminated the risks of ICSI, but not of IVF. But frozen embryos also had increased risk of macrosomia.

This is the paper that Stephen mentions; but it’s not the only one to report potential risks associated with IVF.  A rather kneejerk response to this is to go “Eeeep!  This means that IVF is dangerous, and we’re harming kids by conceiving them by this method”.  (I suspect that there’s an element of that in posts like this – though admittedly if that element is there, it’s being deployed merely as a part of a wider attack on IVF, motivated for different reasons.)  But, of course, kneejerk reactions are rarely all that morally insightful, and the conventional response to concerns about IVF is rather more sanguine.

Borrowing heavily from Parfit, the standard response is this: each of us is reliant on a particular egg and a particular sperm having fused in a particular way.  Had that been different, we would not have come into being.  A month later, and it’d’ve been a different egg; and it could easily have been a different sperm cell.  Any resultant child would be related to us only in the same way as a sibling – except that it wouldn’t be our sibling, because we wouldn’t be there.  This indicates that, if IVF represents a child’s only chance of coming into existence – and it probably is – it is hard to say that the child has been harmed or wronged thereby.  There may be a qualification to add, along the lines that should the child’s life be so bad that non-existence would be preferable, existence may be a harm; but that kind of outcome is probably hyperbolic in practice.  An elevated risk of any congenital characteristic is therefore unlikely to count as a harm.

So, as Stephen points out, we can ask a question: more…

Some stories, if true,

2 Dec, 13 | by Iain Brassington

just don’t need additional comment:

The Italian woman was sedated and her baby delivered against her will, after Essex social services obtained a court order in August 2012 for the birth “to be enforced by way of caesarean section”.

[...]

After the C-section, the woman, who has two other children and is divorced, was sent back to Italy without her daughter. She returned to Britain in February to request the return of her daughter, who is now 15 months old, but was told at Chelmsford Crown Court that she was to be put up for adoption in case her mother suffered a relapse.

UPDATE: Essex CC has a statement here.  Thanks to Nathan Emmerich for the pointer via twitter.

UPDATE 2: There’s a really good analysis at Pink Tape.

UPDATE 3: The judgement about adoption.

UPDATE 4: And the judgement about the caesarian.

Italian Pop Music’s Role in Bioethical Debate

12 Feb, 13 | by Iain Brassington

Sadly, the list entitled “Great Moments in Italian Pop” is short; but the entry that must surely be at the top is probably very near the top of the list entitled “Great Moments in All Pop”.  It’s a 1972 song by Adriano Celentano.

Prisencolinensinainciusol.

It’s pure gibberish – a parody of what anglophone pop sounds like to people who don’t speak English.

I mention it here for a couple of reasons.  The first is that it’s great.  The second is that it’s a nice way of talking about people who appear to be going through the motions of thinking about ethical matters, but who just get it wrong, and are actually talking gibberish.

Via Dominic Wilkinson, this gem from BioEdge is a lovely example of bioethical prisencolinensinainciusol.  On the face of it, it’s a plea for consistency when it comes to policymaking.

[I]n the Australian state of Queensland [...], the police union has argued that pregnant women who abuse alcohol should be forced to live in safe houses. “Those [unborn] children also deserve a right to full life and health and should not be disadvantaged simply because of the actions or inaction of their birth mother,” said Union president Ian Leavers.

Obviously this is a controversial issue, but I can’t understand how one can both defend access to legal abortion and lock up women who might harm their children.

The link provided is to The Australian, which is behind a paywall, so not something I can access.  However, News.com.au carries the story, too, reporting Union president Levers to have said that the state should be able to intervene in cases where children are at risk of foetal alcohol syndrome and drug addictions.

“Those children also deserve the right to a full life and health and should not be disadvantaged simply because of the actions or inaction of their birth mother.  The state must have the ability to intervene and protect the unborn child when its mother refuses, or is incapable or unwilling to do so.”

Mr Leavers said tougher laws would complement the criminal code, which provides for a charge of killing an unborn child or grievous bodily harm for any person who violently kills or harms an unborn child.

This is a bit odd, all told.  I mean: it might be easy enough to agree that pregnant women probably ought to reduce, or even eliminate, certain behaviours.  But the idea that that might be a matter for the law is very strange indeed.  What would the sanction be?  Is the idea that it’d be better for pregnant women to be in prison?  Fined?  And what about the plausible claim that alcohol or drug abuse is itself a health problem?  Or the distinct possibility that women who do drink or use drugs are much less likely to seek any medical advice at all during their pregnancy if they think that the state might punish them for their behaviour, thereby making a suboptimal situation even worse?  Legal intervention of the sort indicated would be both cack-handed and unjust.

But what about BioEdge‘s plea for consistency?  From what I can see, there’s a fairly obvious set of rejoinders.  First, the police union can say what it likes about what the law should be, but the role of the police is to enforce the law as it stands.  So not interfering with a woman’s legal right to abortion is not the same as defending it.  Likewise, mooting the idea that women might be sanctioned for risking the health of the foetus is not the same as locking women up.  BioEdge seems to have got the difference between voicing an idea, and enforcing a policy, utterly the wrong way around.  BioEdge‘s writer makes it sound like a moral argument is being made; but, really, it isn’t.  Second, that it’s odd to defend abortion but advocate sanctions against risky behaviour in pregnant women may be true – I mean, it’s not a crazy suggestion – but it doesn’t follow from that that one ought to change one’s mind about abortion (which is, I think, given BioEdge‘s commitments generally, what the implication is): all else being equal, and given a whole truckload of secondary arguments about the moral status of the foetus and the moral status of the mother, it’s at least prima facie more likely that it’s the risky behaviour claim that’s off.  Third, that the representative of a policing union has made a statement about what the law should be is in no way an indication that that statement should be taken seriously.

Come on, BioEdge.  Fair play to you: you look like you’re doing the job… but… Prisencolinensinainciusol.

Maybe there’ll be richer pickings from the other story behind the link.  In Tasmania,

the premier and deputy premier have released a long report on legalised euthanasia. They insist that there is no “sound evidence” of potential elder abuse. However, rates of child abuse are nearly 60% higher there than in other Australian states. Isn’t that a bit inconsistent? The kind of people who abuse children probably won’t mind abusing grannies.

Ummm… wait a sec: What?

JME blog homepage

Journal of Medical Ethics

Analysis and discussion of developments in the medical ethics field. Visit site

Latest from JME

Latest from JME

Blogs linking here

Blogs linking here