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

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?

But that’s not what it says, is it?

25 Jan, 13 | by Iain Brassington

Today’s blast of righteous indignation is directed towards New Mexico.  House Bill 206 says, in essence, that… well, it’s short, so here it is in full:

HOUSE BILL 206

51ST LEGISLATURE STATE OF NEW MEXICO - FIRST SESSION2013

INTRODUCED BY

Cathrynn N. Brown

AN ACT

RELATING TO CRIMINAL LAW; SPECIFYING PROCURING OF AN ABORTION AS TAMPERING WITH EVIDENCE IN CASES OF CRIMINAL SEXUAL PENETRATION OR INCEST.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:

SECTION 1.  Section 30-22-5 NMSA 1978 (being Laws 1963, Chapter 303, Section 22-5, as amended) is amended to read:

“30-22-5.  TAMPERING WITH EVIDENCE.–

A.  Tampering with evidence consists of destroying, changing, hiding, placing or fabricating any physical evidence with intent to prevent the apprehension, prosecution or conviction of any person or to throw suspicion of the commission of a crime upon another.

B.  Tampering with evidence shall include procuring or facilitating an abortion, or compelling or coercing another to obtain an abortion, of a fetus that is the result of criminal sexual penetration or incest with the intent to destroy evidence of the crime.

C.  Whoever commits tampering with evidence shall be punished as follows:

(1)  if the highest crime for which tampering with evidence is committed is a capital or first degree felony or a second degree felony, the person committing tampering with evidence is guilty of a third degree felony;

(2)  if the highest crime for which tampering with evidence is committed is a third degree felony or a fourth degree felony, the person committing tampering with evidence is guilty of a fourth degree felony;

(3)  if the highest crime for which tampering with evidence is committed is a misdemeanor or a petty misdemeanor, the person committing tampering with evidence is guilty of a petty misdemeanor; and

(4)  if the highest crime for which tampering with evidence is committed is indeterminate, the person committing tampering with evidence is guilty of a fourth degree felony.”

SECTION 2.  EFFECTIVE DATE.–The effective date of the provisions of this act is July 1, 2013.

The new bit is section B.

In a statement, the congresswoman who introduced the Bill, one Cathrynn Brown, said that her intention was to punish the person who commits incest or rape and then procures or facilitates an abortion to destroy the evidence of the crime.

Hmmm.  Except that that’s not what it says, is it?  Maybe she should read the text of her own Bill.  It talks about procuring an abortion, as well as compelling or coercing another person to have one.

I think that the second bit is actually fairly unobjectionable.  To compel someone to have a medical procedure, whomever that someone is, and whatever the procedure, is to wrong them; and if you compel them to have the procedure in order to remove evidence of another wrong, then the wrongness is multiplied.  But, y’know… that first bit… um… more…

Double Effect in the Halappanavar Case

5 Dec, 12 | by Iain Brassington

In the wake of Savita Halappanavar’s death, a statement was issued by the Irish Catholic Bishops’ Conference.  The whole thing is available here.  However, I think that a couple of paragraphs is particularly worth picking out:

Where a seriously ill pregnant woman needs medical treatment which may put the life of her baby at risk, such treatments are ethically permissible provided every effort has been made to save the life of both the mother and her baby.

Whereas abortion is the direct and intentional destruction of an unborn baby and is gravely immoral in all circumstances, this is different from medical treatments which do not directly and intentionally seek to end the life of the unborn baby. Current law and medical guidelines in Ireland allow nurses and doctors in Irish hospitals to apply this vital distinction in practice while upholding the equal right to life of both a mother and her unborn baby.

I think that the first of these paragraphs is pretty unexceptionable, and describes something approaching the default setting for medical interventions anyway.  We might want to talk about “reasonable efforts” rather than “every effort”, since the latter does perhaps tend towards the onerous; but the general gist seems OK to me – almost trivially so.

Note, though, how a great deal rides on a distinction between different kinds of pregnancy-terminating procedure (PTP, from now on).  Notably, there’s a line drawn around abortion as a particular form of PTP.  The statement admits that certain PTPs may be permissible: what matters is that there should be no intention to kill.  Thus certain PTPs may be permissible notwithstanding foetal death if that death is not intended.  I take this to mean that, should the foetus survive, permissible PTPs would be those in which there is no sense that the procedure had gone wrong.  Abortion would be the kind of PTP that is impermissible, precisely because the intention is to kill.  (At the extreme, successful delivery is a kind of PTP, too, since it does end the pregnancy – it’s just that it’s the kind of PTP that we celebrate, rather than tolerate.)

Fairly clearly, the Bishops’ statement relies on some form of the Doctrine of Double Effect: the idea that there’s a moral difference to be had between intending some outcome, and foreseeing it.  If the Doctrine holds water, it would provide a way to say that acting in order to shorten a life may have one moral value or require one moral argument, but acting despite a foreseen shortening may have or require another.

Now: put that slightly to one side, but keep it simmering while we look at something else. more…

All Right, Peter: I’ll Bite

1 Nov, 12 | by Iain Brassington

Over at the CMF blog, Peter Saunders has a slightly peculiar post.  He begins by criticising Today programme presenters for not being hard enough with someone whose husband had gone to Dignitas; but then turns his attention – via a jibe at the rights made-to-order all-purpose bogey man, the “liberal elite” – to what he calls ten questions that you never hear asked in the media about abortion.

Here they are:

1. You say you support a woman’s right to make her own reproductive choices in regards to abortion and contraception. Are there any restrictions you would approve of?

2. In 2010, The Economist featured a cover story on “the war on girls” and the growth of “gendercide” in the world – abortion based solely on the sex of the baby. Does this phenomenon pose a problem for you or do you believe in the absolute right of a woman to terminate a pregnancy because the unborn fetus is female?

3. In many states, a teenager can have an abortion without her parents’ consent or knowledge but cannot get an aspirin from the school nurse without parental authorization. Do you support any restrictions or parental notification regarding abortion access for minors?

4. If you do not believe that human life begins at conception, when do you believe it begins? At what stage of development should an unborn child have human rights?

5. Currently, when genetic testing reveals an unborn child has Down’s Syndrome, most women choose to abort. How do you answer the charge that this phenomenon resembles the “eugenics” movement a century ago – the slow, but deliberate “weeding out” of those our society would deem “unfit” to live?

6. Do you believe an employer should be forced to violate his or her religious conscience by providing access to abortifacient drugs and contraception to employees?

7. Alveda King, niece of Martin Luther King, Jr. has said that “abortion is the white supremacist’s best friend,” pointing to the fact that Black and Latinos represent 25% of our population but account for 59% of all abortions. How do you respond to the charge that the majority of abortion clinics are found in inner-city areas with large numbers of minorities?

8. You describe abortion as a “tragic choice.” If abortion is not morally objectionable, then why is it tragic? Does this mean there is something about abortion that is different than other standard surgical procedures?

9. Do you believe abortion should be legal once the unborn fetus is viable – able to survive outside the womb?

10. If a pregnant woman and her unborn child are murdered, do you believe the criminal should face two counts of murder and serve a harsher sentence?

Some are easy to answer; others require a bit more argument.  I’m not in the media, I’m more left than liberal, and anyone who’s read any of my work knows I’m miles from being part of an elite.  But I’m not going to let that stop me.  Maybe others could offer their answers in the comments, either here or on the CMF site… more…

Mouse Eggs: A Cool Solution to a First-World Problem?

8 Oct, 12 | by Iain Brassington

The news that Japanese researchers have successfully induced skin cells to behave like viable eggs, which have then been fertilised to create a new generation of mice, may well come to be seen as a scientific milestone.  And if it’s not that, it’s definitely very, very cool.  (The original paper is here.)

Though the research does not necessarily translate into humans, it appears to demonstrate that the genetic material found in every cell in the body can be put to use in the creation of offspring. In principle, this offers infertile women the opportunity to have children that are genetically related, even if they do not have viable eggs of their own: cells from another part of the body could be used and “reprogrammed” to behave as eggs would.  (Putting the procedure to use in humans would be illegal under current UK law, since the synthesised eggs would not be what the Human Fertilisation and Embryology Act calls “permitted”.  But the law is, after all, just the law.)

There will probably be concerns raised; but they aren’t obviously any more serious in relation to this technology than they would be in relation to others.

The most obvious concern – and, prima facie, the most powerful – would be about the safety of the procedure were it to be used in humans. more…

IVF and Birth Defects: Is there a Moral Problem?

21 May, 12 | by Iain Brassington

It was reported a couple of weeks ago that researchers had found a link between certain forms of assisted conception and an increased risk of birth defects.  The paper, published in the NEJM, suggested that ICSI (intra-cytoplasmic sperm injection) correlated with defets in just about 10% of births.  The base rate is about 5.8%, rising to around a 7.2% defect rate from IVF.

Does this tell us anything of any great moral import?

Several things spring to mind.  One is that, granted the claim that it’s better not to be born with a defect, it’s presumably also better for assisted reproduction not to elevate the risk of defects above the natural level.  There might even be an obligation to do more research into assisted reproduction, so that we can ensure the fewest possible birth defects (and maybe get better at generating healthy babies than nature: even a rate of 5.8% looks a bit slapdash).  Slightly more radically, some might claim that there ought to be a moratorium on certain assisted reproduction procedures – ISCI in particular – for the sake of minimising the number of birth defects.

Let’s deal with the radical claim first (what can be said about that will also speak to the less radical one). more…

The benefits of contraception?

14 May, 12 | by David Hunter

The government in New Zealand is proposing to spend $1 million of funding for women on a benefit and their teenage daughters to get long-term reversible contraception – such as an implant. Advice on accessing this treatment and its implications will be provided by case workers in the Social Services.

The NZ government seems almost surprised that some people have been offended by the suggestion of this policy asserting that this is not interfering in the reproductive life of beneficiaries, and is just common sense – the Prime Minister John Key said

“Ultimately if people have unplanned pregnancies and are solely dependent on the state, you the taxpayer have to pay for a long period of time for that dependency and we know the outcomes aren’t terribly good.”

While I think they are quite right that this is not interfering in the reproductive life of beneficiaries this doesn’t exhaust the potential array of ethical issues involved in this sort of proposal.

It isn’t inherently coercive since offers are typically not coercive. However the close association between medical care and social services seems a little more sinister since it makes a connection (however unintended) between receiving social support and receiving this reproductive advice – and perhaps in the minds of some in taking it.

Could this connection be abused? Certainly. As one beneficiary notes

“she had already been told by a case officer to “shut your legs” I’ve even heard WINZ people say things worse than that to women. “I go in there for a fight, for an argument, every time. There are people in there who have huge power control issues and they just make it worse for us. They take their job description way too far.”

This doesn’t surprise me at all, any time policy is implemented it will sometimes be misapplied. And Work and Income New Zealand (WINZ) can be somewhat inflexible – when my first wife Kerry passed away I had to cancel her sickness benefit (she had cystic fibrosis) so her brother and I went into the nearest WINZ office to inform them. We were told we would need to fill in a change of circumstances form, and once we had completed this we were told that they couldn’t accept it because it would need to be signed by the recipient of the benefit… We eventually sorted it out, although we left with a copy of the paperwork to show to her…

Ronald Dworkin in his book Sovereign Virtue argues that the first and heaviest responsibility of a government is to treat its citizens equally. Does this constitute equal treatment? Targeting those on benefits in this way doesn’t seem to to me.

Providing long term contraception in general is a good thing (assuming cost-effectiveness & safety of course) since it provides for greater reproductive autonomy. But I’m not sure reproductive services ought to be targeted at the poor in this fashion. It seems to display the attitude of the government towards the reproduction of some of society’s poorest members – namely that it would be better if they didn’t breed – or as the government puts it “breaking the cycle of intergenerational welfare dependency”. And I am not sure that is an attitude that is defensible. While solving the cycle of intergenerational welfare dependency would be laudable, this strikes me more as a dissolution than a solution to the problem.

How Abortion Law Works in Texas

16 Mar, 12 | by Iain Brassington

Remember a little while ago there was a rash of proposals in the US that’d force women to see a sonogram of the foetus, or to listen to detailed descriptions of it, before having an abortion?

Yeah: them.  Well, via Ophelia, here’s an account of what really happens.

Halfway through my pregnancy, I learned that my baby was ill. Profoundly so. [...] “I’m worried about your baby’s head shape,” she said.  “I want you to see a specialist—now.”

[... B]efore I’d even known I was pregnant, a molecular flaw had determined that our son’s brain, spine and legs wouldn’t develop correctly.  If he were to make it to term—something our doctor couldn’t guarantee—he’d need a lifetime of medical care.  From the moment he was born, my doctor told us, our son would suffer greatly.

So, softly, haltingly, my husband asked about termination.  The doctor shot me a glance that said: Are you okay to hear this now?  I nodded, clenched my fists and focused on the cowboy boots beneath her scrubs.

She started with an apology[...]

That’s not a good start, is it?  An expression of sympathy, maybe.  But an apology?  It’s as if she knows that things are about to get worse.  And they are. more…

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