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the use of advanced reproductive medicine by people without a
medical disorder appropriate?
Paradigm for Practice
Academic Exchange September
1999 Contents Page
Molly had tried for years
to conceive. Her husband, Bill, was supportive, but they both
felt anxious, helpless, angry, and enormously frustrated with
The cause had been defined--her uterus would not support a pregnancy.
Ten years ago there would have been no hope, but today she and
Bill could have their own child if they could find someone to
carry the baby for them. The questions posed by this option were
overwhelming. What would be the legal issues? Would the baby
belong to Molly or to the woman who carries the child? Would
society perceive their child as different? How would they tell
their child about the delivery? If Bill and Molly were to divorce,
could the surrogate mother take the baby away? What were the
Perhaps even more controversially, what if Molly and Bill were
not infertile? What if Molly did not want to bear children herself?
What if they sought a surrogate mother simply because she wanted
to avoid the pain, delivery risks, and inconvenience of a pregnancy?
These scenarios sound like made-for-TV movies, yet the situations
are real-life dramas that play out in a complicated and often
confusing medical legal system. Assisted reproductive technologies
have allowed pregnancy where never before possible. Society,
however, has been unable to keep up with the consequences of
this fast pace of advancement.
In a world where population growth is a major concern, there
is often little political support for those unable to have children.
Do all citizens have the personal reproductive freedom to choose
or not choose a mate, male or female? And if a couple wishes
to have children, can they choose to do so at their convenience?
These questions are not as easily answered today as in the past,
when reproduction was limited by the function of the reproductive
system. Today, revolutionary advanced reproductive technologies
allow the in vitro combination of gametes taken from one's own
body or a donor egg or sperm for fertilization. It also allows
the placement of embryos into one's own or another uterus to
allow the growth and development of a human being. The real dilemma
is for physicians who specialize in infertility to try to define
Infertility is a medical disease in which the reproductive system
does not function. Reproductive endocrinology and infertility
is a medical specialty for the treatment of men and women who
cannot have children. There are some single women and lesbian
couples, however, who request artificial insemination with donor
sperm. Their rights to be without a male partner should be respected.
Moreover, many support their right to have a family. The argument
centers around the use of donor sperm to treat severe male infertility,
as opposed to using donor sperm to assist women without a male
partner. Robert Stillman, Professor of Obstetrics and Gynecology
at Georgetown University, summarizes: "The discussion is
not an argument for, nor does it support the concept of social
Darwinism [i.e., determining fit parentage]. The point under
discussion is the use of medical services by individuals who
do not have a medical disorder."
Interestingly, there are legal limitations on the use of infertility
services for infertile patients, particularly in Europe. In France,
the law concerning assisted reproduction states, "Assisted
reproduction is intended to remedy a state of infertility, the
pathologic nature of which has been medically diagnosed"
(Article l-152-1). Thus, a man and woman must be alive, of reproductive
age, and married or able to prove two years of living together
(Article l-141-2). Jacques Lausac notes in his recent article
in Human Reproduction, "It is clear that the law is intended
for use in a medical context and excludes all social demands."
In the United States the debate continues. Although there are
some laws that regulate embryo laboratories and restrict embryo
research, the private sector is essentially not regulated. Most
physicians have chosen to avoid the social use of our technologies
and skills beyond patient care. Other physicians, however, are
less concerned and actively practice "boutique medicine."
John A. Rock is the James
R. McCord Professor and Chair of the Department of Gynecology