Season 4, Episode 10: What It Feels Like

THE NEW AGE OF REPRODUCTION

CASE: DESPERATELY SEEKING STEM CELLS

In a case similar to the one in tonight's episode, an older couple is desperate to use new reproductive technology to conceive a child. Their older child, now 8, is very ill, having relapsed after battling leukemia for 5 years. No suitable match for the only treatment that might save his life, a blood stem cell transplant, can be found. The couple hopes that, using their own eggs and sperm, several 'test tube' embryos will be conceived, one of which will be a suitable donor match for their son. That embryo would be 'chosen' to be implanted into the mother and the needed stem cells would be harvested from the child's umbilical cord at birth. The hospital staff is reluctant to help the parents as they view the creation of an embryo for the benefit of another person as morally troublesome. The couple counters that they "want another child and will love it."

Reproduction used to be a fairly simple matter: woman, man, sex, birth, child. Infertility was less of a problem than the childbirth-related death of mother and child. As with so much else in the past century, however, the situation may now be much safer but not as straightforward. You do not, directly at any rate, need a man to be there; you do not, except initially, need a woman to be there -- well, okay, a woman's uterus is still needed but almost any uterus will do. Age, sexual orientation, infertility, a lack of sperm or eggs, even death, are all no longer limitations to successful reproduction. If the continuation of one's chromosomes is the rationale for evolution, then modern assisted reproduction technologies have given our genes a way of replicating almost without us.

Sperm can be provided and joined with an ovum in a Petri dish (an in vitro embryo); sperm can be injected directly into an ovum (ICSI: intracytoplasmic sperm injection); fertilized eggs, embryos, blastocysts, can be implanted in the mother's womb (IVF: in vitro fertilization); the womb may be that of a surrogate mother; sperm can be preserved from the testes prior to castrating radiation or surgery or even harvested at death. Other techniques - such as Pre-implantation Genetic Diagnosis - can be used to screen embryos for their genetic make-up including gene-linked diseases. 'Assisted reproduction technologies' (ART) include these and other services, techniques, and technology used to assist individuals who cannot conceive on their own.

Regulation of ART

The proliferation of ART exists in an international patchwork quilt of regulations and regulatory vacuums. Not surprisingly, there is little harmony in this area. For example, the United States does not as yet regulate pre-implantation genetic testing on embryos, while the United Kingdom and Canada do, to varying extents. The regulations are partial, in flux, and poorly enforceable.

Canada, similar to many other countries, has scrambled to keep up with the advances in reproductive medicine. New legislation to provide direction in this troubled area -- the Assisted Human Reproduction Act (AHR Act) - was passed in 2004. This AHR Act defines certain activities as unsafe or unethical, recommending criminal sanctions if they are performed. For example, human cloning is prohibited.

The AHR Act addresses concerns that unregulated ART could undermine the fundamental principle of respect for persons embodied in medicine. This principle of respect attempts to exclude monetary gain as the primary motivation for the actions of healthcare professionals - doctors, nurses, etc. - working in this field. For example, in Canada, surrogate mothers cannot 'profit' from carrying a child to term; they can only be reimbursed for reasonable costs and losses of pregnancy - this is to remove any financial windfalls to them and prevent a market-driven traffic in babies and "wombs for hire."

Cord blood stem cells and "saviour siblings"

Hematopoetic stem cells - or stem cells of the blood system - are primal cells able to renew themselves through cell division and also possessing the capacity to differentiate into more specialized blood cells. These cells have been used for some time to treat leukemia and related types of cancers via bone marrow transplants. As discussed in Facts Behind the Fiction, cord blood also contains these blood stem cells.

What is controversial in the above case is using ART for the creation of an embryo - and presumably the sacrifice of the mis-matched ones - to benefit an existing child. As a human embryo is a potential human being, so the reasoning goes, destroying it contributes to the devaluation of human life. It treats human life as a means to an end, rather than as an end in itself.

The renowned 18th century Prussian philosopher, Immanuel Kant, argued that human beings should never be treated just as a means to obtaining some supposed 'greater good' as this renders them mere 'stepping-stones' to someone else's welfare or happiness. He believed in the intrinsic value of each individual's life. By the lights of the Kantian view, parents ought never see potential offspring as mere extensions of themselves and their own needs.

Is the Kantian view of offspring too precious, though? After all, parents have children for all kinds of emotional, economic, and cultural reasons, but our culture does not privilege one set of reasons. There is no moral litmus test prospective parents must pass - we do not question why they want a new child. So, why not, then, produce an offspring to save the life of an imperiled one?

Back to the Case

There would be little reason to hesitate with sibling-to-sibling bone-marrow donation if the suitable donor child already existed. Presuming the risks to be undertaken by the healthy sibling are small and the psychological benefits to the family so evident, were the ill child to survive, then donation could take place. To think otherwise, to pause even for a moment, is what the 20th century philosopher Bernard Williams has called "having one thought too many." The 'rescue' response should be automatic.

Would it be any more wrong if the parents had to conceive an embryo to save the life of their imperiled child? If doing so were acceptable to them and easy to do (for example, they wanted another child anyway, they were young, could afford it), who would - or should - stand in their way?

The most important aspect of reproduction - love of parents for the new life to be - is retained despite the use of ART. One could even say the use of ART may preserve and enhance a loving family should the sick 8 year old be saved. Is it better to let a child die than utilize ART to save the child? If common sense intuitions have any role here, it would seem that the harm caused by the loss of an actual life is greater than the harm done by the loss of a potential life.

Other people would refuse to trade one human life (the embryo's) for that of another (the child's) - this is similar to the Kantian view of human life. One worry is that using an embryo, even for a valid therapeutic purpose, might open the floodgates to raising and harvesting embryos for the purpose of being tissue or organ factories. This worry might be countered if ART were to be strictly regulated and offered only by accredited facilities, as recommended in the AHR Act and similar laws elsewhere. It seems also a rather abstract and distant worry as compared with the palpable grief that would be caused by the death of this couple's child.

The current byzantine worries about the use and abuse of stem cells and embryos may disappear as science finds new ways to make stem cells - say, from adult sources. In the meantime, the ethical challenges of the use of new ARTs will remain.

-- Philip C Hébert, MD, PhD

About the Author

Dr. Philip Hébert is an Associate Professor in Family Medicine at Sunnybrook Health Sciences Centre and a member of the Joint Centre for Bioethics at the University of Toronto. He has a PhD in philosophy from York University in 1983 and completed his medical degree from U of T in 1984. Dr. Hébert is the author of, "Doing Right: A Practical Guide to Ethics for Physicians and Medical Trainees", published by Oxford University Press in 1996. A revised, second edition is to be published in summer of 2008.

Want to read and learn more?

Read more about assisted human reproduction and informed consent by clicking here:
http://www.parl.gc.ca/information/library/PRBpubs/prb0635-e.htm

Check out "Surrogate pregnancy: a guide for Canadian prenatal health care providers" here:
http://www.cmaj.ca/cgi/content/full/176/4/483

Learn more about the case described above by reading the article, "Couple hopes 'saviour baby' will provide stem cells for son" here:
http://www.cbc.ca/health/story/2008/04/14/bc-stem-cell-baby.html?ref=rss