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Is the use of advanced reproductive medicine by people without a medical disorder appropriate?

Justified discrimination?
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One 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 their situation.

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 religious implications?

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 limits.

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 and Obstetrics.