From IVF to Immortality: Controversy in the Era of Reproductive Technology

Ruth Deech and Anna Smajdor
OUP 2007
ISBN 978-0-19-921979-7
RRP: £16.99

Reviewed by Matt James

Publicised as a book for those who seriously want to engage with the challenges and controversies which artificial reproductive technologies (ART) present, “From IVF to Immortality: Controversy in the Era of Reproductive Technology” is a cross-disciplinary analysis of the complex bioethical and social problems surrounding reproductive technology. The analysis incorporates legal, philosophical, ethical, and regulatory aspects in order to create a lucid and engaging read primarily aimed at an academic readership but accessible to a much broader audience.

The book's aims

The book’s authors are well respected and well known figures within the field. The lead author, Baroness Ruth Deech was the former chair of the Human Fertilisation & Embryology Authority and is a Crossbench peer in the House of Lords. Anna Smajdor is an Honorary Research Associate in Bioethics at Imperial College London. Essentially the book has three main aims. Firstly, the book seeks to provide a clear account of all the techniques involved in ART. Secondly, it seeks to look at ART and the moral, philosophical and legal issues which it raises, particularly with regard to surrogacy, single or same-sex parenthood, saviour siblings, reproductive cloning and embryo research. Thirdly, due to the somewhat controversial role the UK has played in the development and regulation of reproductive technologies, it addresses the framework with which these technologies are regulated by critically examining the role of the Human Fertilisation and Embryology Authority (HFEA) before engaging in a short comparative study between other countries in this regard.

Consisting of eight chapters, the book opens with an introduction about the context surrounding the creation of the Human Fertilisation and Embryology Authority (HFEA). An overview of the legal framework of the Human Fertilisation and Embryology (HFE) Act is provided along with a concise commentary on the positive and negative implications of the place and role of the media and political and ethical issues.

Scientific background to ART

The first chapter proceeds to provide a scientific and historical account of the advent of assisted reproductive technologies (ART) with particular reference to the birth of Louise Brown in 1978. The chapter adopts a clear and systematic approach to dealing with the material by taking as its starting point, a full and detailed account of natural reproduction. This context is used to identify potential problems incurred with natural reproduction and the part ART can play in potentially resolving these problems. Particularly attention is paid to artificial insemination, in vitro fertilisation (IVF) and pre-implantation genetic diagnosis (PGD). Both the successes and risks associated with such techniques are covered which allows the reader to fully comprehend the full breadth of developments which have occurred in this field.

The ethical and moral principles which affect discussions regarding fertility are addressed in chapter two. Issues of autonomy and safety, consent and public good and privacy are tackled with direct reference to real life case studies which help to exemplify the theory and practicalities of the issues involved.

Making the progression from the principles discussed in the preceding chapter, chapter three addresses perhaps the three main contentious issues currently associated with ART, namely saviour siblings, designer babies and sex selection. Starting with PGD, the authors explain what is involved in the procedure and the uses it is put to before moving on to explore the criteria which are often used to make the distinction between serious and non-serious conditions that are deemed to warrant the use of PGD. Details are given on the HFEA’s consultation processes which are undertaken in order to ensure its policy on the use of PGD takes into account advances in medical treatments as well as the current mood of public opinion. This is shown particularly when looking at sex selection and the use of PGD in order to create saviour siblings. This is perhaps one of the most controversial uses of PGD and is discussed in the context of the case surrounding the Hashmi family. Two key issues seem to emerge in this discussion. The first issue concerns how the argument that a human is not merely a means to an end, whilst an important consideration, can result in the oversimplification of the complex moral and ethical issues involved. Secondly, the issue of media power and how the media can significantly shape public opinion both positively and negatively. The authors note that for every group that does speak out either for or against a decision made by the HFEA, there is a probably another group which agrees with the decision whose voice is either not heard or who do not speak out. Consequently, the debate can become polarised, leading to the need for the HFEA to avoid pandering to pressure from the media and to instead set a course which interprets and applies regulation while taking into consideration all points of view. On the one hand, this is a very helpful chapter as more than just theoretical approaches are presented; much consideration is also given to how the theory is implemented. Yet on the other hand, a more healthy critique of the procedure would be more helpful. Whilst the reader is given the basis for the HFEA’s decision, it is suggested that a critique of the final decision and whether or not it turned out to be the best decision in the end would bring a more balanced and thorough set of perspectives. Greater depth and explanation to the practicalities of how the HFEA interprets and applies regulation, whilst taking into consideration all points of view, is also an area of discussion that is lacking at this point.

Feminist perspectives

Chapter four addresses feminism and its stance on female autonomy and assisted reproduction. The chapter covers issues such as egg freezing and older mothers, reviewing the legal and ethical implications associated with these issues. The chapter helpfully highlights and explores the issue of autonomy and how respect for autonomy can be exhibited in one or both of two ways. First, respecting reproductive autonomy by abstaining from physical intervention in women’s reproduction lives, thereby not forcing contraception. Alternatively, reproductive autonomy can be respected by facilitating female reproduction choices. Intuitively it may seem that the first approach is the more important. However, since there are no rules or regulations which restrict fertile people from bearing and conceiving children, it becomes discriminatory to apply rules and restrictions to the infertile. The chapter proceeds to discuss access to fertility treatment and the risks involved before proceeding to survey future developments in this area such as artificial gametes and artificial wombs. Whilst from one perspective, an achievement for medical science, such developments also promise to be highly controversial “breakthroughs”.

In chapter five the focus turns to address the tensions between individual desires and public accountability and coherence in the law. The great strength of the book is that is not exclusively a weighty theoretical account but focuses on application congruent to the theory. In this chapter, the case of Diane Blood is studied in great detail. The focus is on the core issues surrounding this case, namely the issues of consent and dignity.

Human Rights

The perspective of human rights with regard to ART is considered in detail in chapter six. With reference to the European Convention on Human Right which was enacted in the UK by the Human Rights Act 1998, various rights based issues are addressed in the chapter. These include prisoners and the right to reproduce, the right to marry, the right to reproductive choice and the right to privacy and family life. Whilst very interesting and nevertheless relevant to the discussion, the chapter was slightly more turgid in comparison to the rest of the book.

The issue of how ART is challenging previously held assumptions as to what constitutes a ‘normal’ family is covered in chapter seven. It poses the question, can the notion of ‘family’ survive at a time where surrogacy is available and parenthood can now be split into genetic, social and gestational components. Rather than a contemporary issue, the authors suggest that this set of circumstances can be traced all the way back to the introduction of the contraceptive pill in the 1960s. Among several issues discussed, a particularly engaging section of the chapter covers donor anonymity and donated gametes. Given the emotive nature of this issue, particularly with regard to whether the child concerned should be allowed to know who their father is, the authors correctly acknowledge that if nothing else then openness and honesty is of crucial benefit to chart a way forward in this regard.

Concerning babies with two mothers, the notion of parenthood is being challenged through the divorcing of the social from the biological. If a woman has genetic abnormalities in her mitochondrial DNA, she can reproduce and pass these abnormalities onto her offspring. Therefore, to resolve this situation the nucleus can be removed from the fertilised egg and inserted into an empty cell, whose mitochondrial DNA is unaffected. However, this causes the identity of the biological mother to be thrown into doubt. Is one of the women the mother or can they both be recognised as biological mothers? Moreover, should a child born in these circumstances have the right to know all those involved in his or her genetic makeup? Due to the complexities involved, the authors discuss two possibilities: allowing these circumstances to give way to broader concepts of genetic parenthood being recognised; and alternatively, adopting an approach that would recognise those persons who support and nurture the child as being the child’s ‘real’ parents. There is also a discussion of surrogacy and same sex parents.

In the final chapter the issue of embryonic stem cells and therapeutic cloning is addressed. Some background science is presented before proceeding to highlight the relative merits and pitfalls of embryonic and adults stem cells. A helpful discussion then follows surrounding the status of the embryo which covers the areas of loss of potential, personhood and special attributes and social harms. The authors acknowledge that the evidence presented may well convince some readers of the special status which should be afforded to the embryo whilst some will process the same evidence to find reason to question the status of the embryo. Moving on to address whether the benefits outweigh the harm, the authors make the interesting point that the very term research implies experimental engagement with the unknown. Should we know the outcome of the proposed research, we would not devote time and energy into carrying out the research. Humans have always had an instinctive urge to push the boundaries to further knowledge and understanding and this is a good desire to have. However, there is need to question how far the boundaries be should extended? Should there be boundaries which are never crossed?

Different perspectives?

In relation to this chapter and indeed the whole of the book, it is disappointing that there is not a greater coverage of different religious bioethics perspectives. To include reference not only to Christian belief but also Islamic, Buddhist and Jewish responses to these technologies would have also brought a richer and diverse analysis to the book’s contents. What is more, justice issues related to the use of ART is also a perspective which is missing from the book’s discussion. The use of new technologies in the field of human reproduction presents both new and old dilemmas. Questions such as to what extent should parents be able to determine (control?) their children's future abilities and character, who has access to these new technologies and how their application affects future generations not only require answers but need to be addressed in mainstream debate. Reference to these perspectives in the course of discussion within the book would have at the very least been useful and helped to promote greater awareness of them.

Before engaging in a comparative study of other countries regulatory approaches, other ways of obtaining stem cells are addressed. These include single cell biopsy through PGD, dead embryos and parthenogenesis. The UK regulatory approach is then compared with the approaches of Germany, Italy and USA. Whilst not a comprehensive review, the account highlights salient points and is more than adequate given the scope of the book in general. Referring to the work of DG Jones and CR Towns, four types of stem cell research regulation are identified. The first is outright prohibition. Secondly, that permission is granted to use stem cell lines. Thirdly, research is only allowed on embryos surplus to IVF, and finally, the option of creation of embryos specifically for research. The authors conclude that given the problems surrounding the status of the embryo concerning various different religious, ethical, cultural political values which can shape regulation on such a matter, it is probably a necessary hallmark of the UK approach that it remains flexible enough to change and adapt to public opinion whilst seeking never to oversell the supposed benefits of stem cell therapies. Regulation will never be able to fully address the ethical questions that such issues raise, but it can seek to enforce regulation which balances trust with progress, acknowledging that it will not be able to please all members of the public. Whilst this may be the aim and intention of the HFEA, the fact that a former chair of the HFEA is one of the authors may tend to heavily skew the perspective being presented. Reference to other sources that may criticise the HFEA’s approach would be a helpful addition to this chapter. The comparison made between the UK and other European countries is a worthwhile inclusion but due to brevity it is probably not detailed enough to pursue the depth of issues which cause the HFEA to take the position it does (both positively and negatively) in comparison to other countries. The book may be said to “critically examine” the role of HFEA but in reality it is lacking in this area.

In conclusion....

Overall, the book is a very helpful volume in which the issues surrounding ART are addressed. The manner in which this is carried out is well crafted and makes for easy reading and comprehension. The use of relevant case study material throughout the book helps to earth much of the theory in every day contemporary life. Having a former chair of the HFEA as co-author of the book offers well grounded and perhaps unrivalled insights into the work of the HFEA and the basis upon which decisions have been made. However, this strength could also be considered a weakness of the book in so far as that at points it presents a rather uncritical and partial opinion on the work of the HFEA. Given the legislation that is currently before the UK Parliament which is seeking to reform the HFE Act, From IVF to Immortality provides a timely appraisal of where we have come from and where we are headed. One thing for certain is that the issues raised by ART do not appear to be disappearing and the pace of advance shows no sign of abating. Therefore, ongoing engagement with these issues is essential and the need to continue to evaluate our assumptions about human nature is paramount. This book may well help in this process by bringing together many strands of the debate thus far in order to determine the future direction of these technologies.

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