Feature

Whose bodies? Whose choice?

Our accepted ideas about parenthood have been overturned by the new reproductive technologies. Yet the ethical debate of recent years has been narrowly technical, and ignored the central position of women, says Patricia Spallone

Now that an egg can be removed from a woman, fertilised in a laboratory dish and the resulting embryo placed in her womb or that of another woman, the question arises, for the first time in human history: ‘Who is the biological mother — the woman who bears a child or the woman from whom the egg came?’

In vitro fertilisation (IVF) is the best known of the ‘new reproductive technologies’ (NRTs) but there are many other NRT methods. In gamete intrafallopian transfer (GIFT) eggs removed from a woman’s ovaries and the sperm of her partner or a donor are put into the woman’s fallopian tube where hopefully fertilisation will take place. Fetal therapy and using fetal tissues to treat conditions such as Parkinson’s disease might also be included in NRT. The term has also come to include any method of ‘assisted reproduction’, such as donor insemination and surrogacy, neither of which are technological nor scientific by definition.

IVF defined the ‘newness’ of the NRTs technologically and socially. Removing women’s eggs is the precondition for many other NRTs such as human embryo research, genetic screening of embryos, and the prospect of gene therapy (genetic engineering) of human embryos. But the technical capability itself is only one aspect of the changes IVF has brought to medicine and to reproduction. The scientific experiments are social experiments of unprecedented proportions.

Remarkably, this level of social change and its effects on women’s lives has provoked little public or professional attention. Instead, much of the government anxiety and medical ethics of the new technology revolves around the human embryo itself and state-of-the-art technology. The whole question of reproductive health care and reproductive medicine has been lost in this discussion.

The assumption that NRTs have brought progress to reproductive medicine, especially infertility treatment, is not borne out. A report for the Greater London Association of Community Health Councils in 1988 contradicts the generalisation that IVF is just another choice among many. In Infertility Services: a Desperate Case, Naomi Pfeffer and Allison Quick noted, ‘We gained a strong impression that, since the publication of the Warnock Report in 1984, the quality of treatment that the majority of the infertile men and women receive within the NHS has deteriorated in some areas although, or even because, in vitro fertilisation and embryo transfer have been introduced’.

They conclude that recent growth of infertility services has been ‘the haphazard result of individual consultant’s interests’. What is needed is better organisation of basic services.

The dominating ethical concern of IVF has been the human status of the embryo, a preoccupation dating at least from the time of the ancient Greeks. For instance in 1982 New Scientist declared: ‘The important ethical question is: should scientists conduct research on live human embryos? When do embryos become people?’

Some of the implications of an embryo-centred ethics became evident when the Human Fertilisation and Embryology Bill 1989 was debated in Parliament. The Embryology Bill, enacted in 1990, was protectionist legislation, but it was mostly concerned with protection of embryos and setting boundaries for medical science. This may sound fair enough, but again it left women marginalised and unprotected.

There were several parliamentary attempts to use the bill to lower the time limit of legal abortion, despite the fact that Mary Warnock, chair of the Committee of Inquiry whose report was the basis of the bill, tried to distance embryo research from the abortion issue. It was always expected that an amendment on abortion would be introduced in conjunction with the Embryology Bill, and it was. Abortion and embryo research were bound to be linked in a debate which spent so much energy on the human status of the embryo and yet so little on women, the human subject of NRTs, the human being whose physical presence is the prerequisite of IVF, fetal therapies, gene therapy of embryos, genetic screening of embryos and so on.

The implications for future medical protection of embryos at the expense of women’s rights is open. In the US a woman can be forced to have a Caesarian section against her will if her doctor can get a court order on the basis of his professional judgement that the fetus at 24 weeks or older would otherwise be endangered. The legal basis for such treatment of women comes from the court’s interpretation of the US Supreme Court’s ruling Roe v. Wade which liberalised abortion.

But broad questions of health care and priorities in reproductive medicine have not been part of the debate. It is extraordinary, for example, that the commercial interests served by the technologies have not been discussed; or that most IVF programmes are offered in the private sector, not on the NHS. These realities are mostly shrugged off, as if they are irrelevant to the development of real services. Yet it is not likely that the private sector would devote time, energy and resources to research into the causes and prevention of infertility.

Infertility was the first medical application of NRTs, and so infertility services are a good place to start thinking about the need for sensitive policy and a better concept of ‘success’ than the technology offers.

This is the place where psychological, emotional, social and cultural considerations should come to bear heavily. There are many dimensions to an individual’s experience of infertility. The NRTs themselves create social and cultural dilemmas. As Dr Frances Price of the Child Care and Development Group at Cambridge recently noted, ‘Far more than facilitation of pregnancy is at issue. Women and men now shoulder new kinds of risk and uncertainty concerning their future relationships, particularly if there has been a donation or a multiple pregnancy.’

A similar point can be made about the genetic applications of NRTs. Genetic illness is now the second and some say more important indication for NRTs. The government’s Clothier Report of the Committee on the Ethics of Gene Therapy (January 1992) lacked any discussion of the implications of embryo or fetal therapy for women: when embryos are the subject of gene therapy they come from and go back to women; when fetuses are operated on in the woman’s womb, there is a woman subject as well.

We are familiar with the tension over abortion. There are similar and very different tensions over other aspects of reproductive medicine. As someone who worked in biomedical research myself, I believe we have been shortchanged by ignoring the differences between scientific priorities, commercial priorities and health care priorities in the pursuit of NRTs. And we have shortchanged ourselves by not attending to the wider medical and social concerns in the development of new technologies of medicine.