Clinical Ethics Discussion 2: The Family and Assisted Reproductive Technology

- Yukari Take and Atsushi Asai*
*Department of Biomedical Ethics, School of Public Health, Kyoto University Graduate School of Medicine, Konoe-cho, Yoshida, Sakyo-ku, Kyoto, 606-8501, Japan

Email: aasai@pbh.med.kyoto-u.ac.jp

Eubios Journal of Asian and International Bioethics 13 (2003), 61-63.


Case

This case study was conducted to discuss the desirable family environment and the wellbeing of children. Although artificial insemination by donor (AID) has been a common practice in some countries for some years, issues surrounding reproductive medicine have become more complicated in recent years. For example, assisted reproductive technology (ART) allows single women and lesbian couples to have children of their own. In addition, according to one report, a woman conceived a child using the sperm collected from her dying husband using a process called electro-ejaculation.

Surrogate parenting is legal in some English-speaking countries. In Japan, an obstetrician arranged a surrogate birth for an infertile couple using the wife's sister as a surrogate mother. In some countries, homosexual couples are allowed to arrange a surrogate birth using the sperm of a partner or of a third-party donor. Technically speaking, this technology allows a single man to have a child of his own. According to a recent report, a woman over 60 years old underwent an in vitro fertilization (IVF) procedure and gave birth to a child. In England, a 59-year old woman gave birth to twins using the same procedure.

Advances in reproductive technology are challenging our traditional notions of family. A child can now have three potential mothers: a genetic mother, a gestational mother and a rearing mother. Whether children with single parents can be as happy as those with both parents is a question that needs careful consideration. Embryo donation and frozen embryo transfer not only allow older and/or infertile couples to have children but also allow homosexual and lesbian couples and singles to start a family. However, are such new parent-child relationships brought about by ART acceptable?

Commentary by Yukari Take, RN, MPH

New parent-child relationships brought about by ART are acceptable in most cases. It is quite natural that homosexual couples would wish to have a child genetically related to one of them. In some countries, gay and lesbian couples are given the same legal rights as traditional couples. Even a dying individual should be allowed to have a child if his partner also has a strong desire to have a child and consents to undergo the necessary procedure. Singles should also be allowed to purchase eggs and arrange for a surrogate birth or purchase sperm and become pregnant. After all, an individual's desire to have a child should not be denied based on a particular point of view. In any case, automatically denying one's right to have a child based on a certain standard is unacceptable because such a standard is most probably biased.

Instead of prohibiting ART, researchers should try to seek ways to solve problems related to ART and provide physical, psychological and social assistance to the family at various stages of the ART procedure (a couple's first visit to a medical institution- childbirth) and child rearing (child's birth- child's independence).

However, as mentioned earlier, there are a few cases in which ART should be prohibited. ART should not be used to alter human genetic information by selecting particular traits or engineering traits using genetic information obtained from several individuals. Assisting an elderly woman to become pregnant by rejuvenating her egg using mitochondrial fluid from a young woman's egg is an example of such genetic alteration. As mitochondria contain a small amount of DNA, children conceived through the technique have genetic material from three parents. It is not known whether this method poses any risks to the children born. In any case, children already born through this method should be given full protection to ensure that they do not suffer any disadvantages because of the way they were conceived.

Although ART should be permitted in most cases, those who are against it may present the following two arguments:

1. New parent-child relationships brought about by ART are ethically unacceptable; in other words, children should be raised by parents genetically related to them.

2. Those who are incapable of providing their children with a desirable living environment should not have children through ART.

However, the point that children are happy only if they are conceived and reared by the parents genetically related to them is baseless. Similarly, just because parents cannot provide their children with a "desirable" living environment does not mean that they are incapable of creating a happy family.

Furthermore, the definition of a "traditional parent-child relationship" is very ambiguous. Such a definition can differ greatly across different times, regions, cultures and, in some cases, even among individuals with the same cultural background. In fact, there are many cases in which children are not raised by parents genetically related to them. In Japan, for example, some children are raised by adoptive parents or by a wet nurse. In old times, spouses did not even live together: A husband visited his wife's premises once in a while, and any child thus conceived was raised by the mother. Some say that a family consisting of a father, a mother and their genetically related child is the product of the industrialized modern world. In other words, family types quite different from those of today were considered normal at different times in history. For these reasons, ART should not be denied just because it challenges our notions of family. Furthermore, children raised by their genetic parents are not necessarily happy. In fact, there are many reported cases of parents abusing their own children. Many married couples in developed countries divorce or remarry even when they have children. In some countries, it is quite common for children to be raised by parents not genetically related to them.

What kind of living environment is considered desirable for children? There are many factors influencing the wellbeing of children, most of which are ambiguous and variable. For example, the provision of sufficient food, clothes and shelter and a good parent-child relationship are essential for the physical and mental wellbeing of children. However, the perceived importance of each factor differs in different times and cultures and is greatly influenced by law, social thought, custom and an individual's subjective point of view. Therefore, it is not realistic to use a uniform checklist to evaluate whether a certain living environment is desirable for raising children. In almost every culture, parents are considered fully responsible for the wellbeing of their children until they come of age. However, without a basic social infrastructure, it is very difficult for parents to provide their children with the necessities of life and to ensure their physical and mental well being. In other words, communities are responsible for providing their residents with a living environment that is desirable for raising children. For these reasons, using a certain standard to judge a couple's ability to provide their children with a desirable living environment or denying their right to have children just because they do not conform to such a standard is unacceptable.

The most important issue when discussing ART is the well being of the child born as a result of the procedure. It is difficult for a third person to determine whether a child is happy because the perception of happiness may differ from person to person. Furthermore, the child's own perception is unreliable until he is old enough to understand and evaluate the situation in which he has been raised. Nevertheless, children conceived and born under any circumstance should be provided with the best possible living environment and must be fully protected to prevent any possible disadvantages they might suffer.

Children conceived through ART could be faced with various problems that children conceived under normal circumstances may never encounter. Parents may not be able to love a child who is not genetically related to them. A child who seeks to find his genetic parents may not be able to get permission to do so from his adoptive parents. In some cases, a child may be born after one of his parents has already died. A child raised by a homosexual couple may face prejudice. Although these circumstances may seem disadvantageous to children, it is quite possible that the children may still live happily. Therefore, it is not justifiable to simply deny couples in such special circumstances their right to have children.

As long as parents are willing and able to raise children, they should be permitted to have children through ART. In order to ensure the wellbeing of the children born, there should be a system to support families at various stages of the ART procedure and through the process of childrearing. Furthermore, society should provide an environment in which children live happily with the fewest disadvantages regardless of the manner in which they were conceived.

Commentary by Atsushi Asai, MD, MBioeth., PhD.

Homosexual couples with a committed relationship should have the freedom to marry each other. People seeking to conceive a child through assisted reproductive technology (ART) should be given the freedom to do so. Women should have complete freedom in the decision to have an abortion. Surrogate parenting should be permitted as long as the child is not treated as a commodity to be delivered for the payment of a price. Parents and children do not necessarily have to be genetically related to each other. There is nothing wrong with changing the traditional concept of family. Choices related to marriage and childrearing should be left to each individual, even if everyone stops having children and humankind is in danger of extinction. There is no reason to prohibit human reproductive cloning if the rights and well being of the cloned child can be guaranteed. Although I cannot justify my positions regarding all topics mentioned above due to limited space, my basic attitude toward various reproductive issues is fundamentally liberal. However, I cannot accept all of new parent-child relationships brought about by ART.

Although homosexual couples should be given the freedom to have children through ART and a child may grow up happily even when he is reared by parents not genetically related to him, there are certain circumstances that may not be suitable for childrearing. For example, a single parent or an elderly couple may have to consider whether they are fully capable of raising a child and whether they can fulfill their obligations as parents. This paper suggests the use of qualification testing to identify whether certain individuals fulfill the fundamental requirements for becoming parents. New parent-child relationships addressed in this case are discussed in relation to the requirements for becoming a parent.

Suppose there were a unique society in which anyone who wished to have children had to take a series of tests to ensure that he was qualified to become a parent. This set of qualification tests was conducted based on the following principle: Because children are weak and totally dependent on their parents, society should have a system to protect and ensure the wellbeing of its children by making sure that they are born into and/or raised in a desirable environment. Even after the child was born, further testing of the parents would be conducted regularly. The first test would be administered when an individual planned to have a child. Individuals who passed the test would be considered capable of fulfilling their fundamental responsibilities as parents until their children came of age. Individuals who fit the following descriptions would be deemed unqualified to become parents. (Children refers to those under the age of 20.):

(1) Those who were unlikely to be with the child as he grew up.

(2) Those who were considered financially incapable of raising a child.

(3) Those who were unlikely to be able to provide their children with stability and love.

(4) Those who were likely to use a child as a means to make money or as a tool to accomplish their selfish desires.

(5) Those who were likely to inflict physical and/or psychological harm or disadvantages on their children.

Although this is a hypothetical case, would testing like this be acceptable in the real world? The following two questions must be answered before one is able to justify the use of such testing:

* Would a society in which such testing existed be a better place for children compared to a society without it?

* Would such testing violate an individual's freedom of reproductive choice?

Theoretically, a society with a system to ensure a parent's capability to raise a child would be more desirable for children than a society without such a system.

First of all, individuals who are likely to die soon should not be allowed to become a parent because a child needs his parents to be with him as he grows up. A child considers a parent someone who is always willing to sacrifice himself for the sake of his child and to give the highest priority to the wellbeing of the child. Therefore, losing both parents, for example, would be a traumatic experience for young children. Some may argue that children who have lost their parents can be raised by foster parents or that society has the responsibility to provide such children with necessary care. However, even when there is always someone to take care of the child, would it be justifiable for parents to have a child when they knew that they were going to die soon? After all, in most cases, there is no substitute for parents. Although children may be raised by caring foster parents, the psychological stress of losing parents is unfathomable. Parental love, which is everlasting and unconditional, is essential to children's wellbeing. Furthermore, as raising a child is an extremely demanding job, elderly parents may not be able to provide the child with all the necessary care.

Secondly, when an individual is incapable of providing his children with the basic necessities of life, i.e., food, clothes and shelter, he should refrain from having a child until he secures a stable source of income. Although such an individual may be able to receive livelihood assistance offered by the local government, seeking to become a parent knowing that he needs to receive substantial assistance to raise a child is a totally irresponsible act both as a parent and as an adult. Only those who have lost their jobs due to uncontrollable circumstances or those who become pregnant without intending to and are financially incapable of raising a child should be entitled to livelihood assistance.

Thirdly, every child needs to be loved by his parents. Parents need to be emotionally stable in order to be able to provide their children with stability and love. Because raising a child is a demanding job that requires a long-term commitment, it is better to have a partner with whom one can share the burden. Although childcare services are available for parents who have difficulties raising a child alone, single parents are often unable to afford such services. Single individuals who seek to have a child and raise the child alone should have enough time, money and emotional stability to ensure child's the wellbeing; however, such a case is very rare. As mentioned above, it is irresponsible to seek to have a child when one needs to receive social assistance to raise a child.

Fourthly, no parent should use his child as a means to make money or as a tool to accomplish his selfish desires. Children should be allowed a certain amount of freedom to make their own choices, and their rights as individuals must be respected by their parents. Every possible measure should be taken to prevent parents from conceiving a child for organs or for money. Conceiving a child for the sole purpose of securing a successor to one's business is also unjustifiable. Parents who conceive a child simply because they want to have a child of their own are likely to respect their child's individual rights. On the other hand, those who conceive a child with the specific desire may inflict a considerable burden on the child. For example, if parents pressure their child to become a soccer player regardless of the child's wishes, the child is likely to be unhappy. However, if parents wish to conceive a child for the purpose of using the newborn child's cord blood to save the life of their other, severely ill, child, such an intention may be justifiable as long as the rights of the newborn are not compromised. Other aspects of this issue require further discussion.

Lastly, any individual who is likely to inflict physical and/or psychological harm or disadvantages on his child should be considered unqualified to become a parent. It is important that the characteristics of such individuals be clearly defined. For example, an individual who has a severe mental illness and is highly likely to abuse a child should not be allowed to conceive a child. In my opinion, there should be a system to prevent all individuals who fit the above descriptions from becoming parents because it is unethical to allow such an individual to conceive a child when it is obvious that the child is highly likely to become unhappy.

Does such testing violate an individual's freedom of reproductive choice? Although everyone has the right to become a parent, such a right is not absolute. The well being and human rights of the child should always be given the utmost consideration because children are weak and totally dependent on their parents for their wellbeing. Therefore, it is justifiable to prevent a single woman who is going to die in two years from having a child through IVF. Similarly, a jobless couple should refrain from having a child until at least one of them has a stable source of income.

Some may argue that our society has the responsibility to help those in need and that the introduction of a system to ensure an individual's capability to raise a child will impose excessive pressure on people to fulfill necessary requirements. However, as mentioned earlier, one should not be totally dependent on social assistance. Although children without parents and single mothers with financial difficulties should be protected, such cases should be prevented if possible. If a society with a system to ensure an individual's ability to raise a child would be more desirable for children compared to a society without such a system, as discussed in this paper, the use of qualification testing for individuals who wish to become parents is justifiable. However, the purpose of this paper is not to recommend the introduction of such testing but is to suggest what kind of environment is desirable for children and what can be done by parents to ensure the rights and wellbeing of children.

In conclusions, any individual who wishes to become a parent should be able to be with the child as he grows up. It is the responsibility of parents to provide their children with the basic necessities of life and with stability and love. Those who are likely to use a child as a means to make money or as a tool to accomplish their selfish desires, or those who are likely to inflict physical and/or psychological harm or disadvantages on their children, should not be allowed to become parents. However, even when a child is raised in special circumstances, such as by gay or lesbian couples or by adoptive parents, he can be happy as long as he is provided with the necessary care and love. On the other hand, a child conceived and raised by a single parent may experience financial instability. A child conceived by an elderly couple or a child conceived using the sperm of a dying husband collected by electro-ejaculation might experience psychological instability from the loss of a parent at an early age. Any individual who plans to have a child has an obligation to ensure that he can provide a child with as desirable an environment as possible.


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