Assisted reproduction and justice: Threats to a new model in a low‐ and middle‐income country

Infertility is an unpredictable but widespread condition. While high‐income countries grapple with when, or how to cover the costs of assisted reproductive technology (ART), such as in‐vitro fertilisation (IVF), these services are generally only available to wealthy persons at private facilities in low‐ and middle‐income countries (LMICs). Although the principle of non‐interference with normal individual reproductive rights is robust, whether it is also the responsibility of collective society to provide the means (when ART applies) to achieve pregnancy, is controversial. Recently, a low‐cost model was developed at a South African public institution. The target population for this model was “helpless and marginalised, childless couples”, but a new threat has arisen, namely, infertile couples who could conceivably afford private care. In the allocation of this scarce resource, we argue for a prioritarian response that first addresses the worst‐off, in order to even out unequal access imposed by sharp differences in income.     

Frozen embryos, genetic information and reproductive rights

Recent ethical and legal challenges have arisen concerning the rights of individuals over their IVF embryos, leading to questions about how, when the wishes of parents regarding their embryos conflict, such situations ought to be resolved. A notion commonly invoked in relation to frozen embryo disputes is that of reproductive rights: a right to have (or not to have) children. This has sometimes been interpreted to mean a right to have, or not to have, one's own genetic children. But can such rights legitimately be asserted to give rise to claims over embryos? We examine the question of property in genetic material as applied to gametes and embryos, and whether rights over genetic information extend to grant control over IVF embryos. In particular we consider the purported right not to have one's own genetically related children from a property‐based perspective. We argue that even if we concede that such (property) rights do exist, those rights become limited in scope and application upon engaging in reproduction. We want to show that once an IVF embryo is created for the purpose of reproduction, any right not to have genetically‐related children that may be based in property rights over genetic information is ceded. There is thus no right to prevent one's IVF embryos from being brought to birth on the basis of a right to avoid having one's own genetic children. Although there may be reproductive rights over gametes and embryos, these are not grounded in genetic information.     

Covert moral bioenhancement,public health,and autonomy

In a recent article in this journal, Parker Crutchfield argues that if moral bioenhancement ought to be compulsory, as some authors claim, then it ought to be covert, i.e., performed without the knowledge of the population that is being morally enhanced. Crutchfield argues that since the aim of compulsory moral bioenhancement is to prevent ultimate harm to the population, compulsory moral bioenhancement is best categorized as a public health issue, and should therefore be governed by the norms and values that apply in public health settings. In this article, I argue for two related claims. First, I question the extent to which compulsory moral enhancement should be considered a public health issue that ought to be governed by the norms and values that apply in public health settings. Second, I argue that Crutchfield's argument that covert moral bioenhancement would better respect people's autonomy than an overt program overlooks two important autonomy‐based reasons that, in fact, favor an overt moral enhancement program over a covert one.     

Reproduction as spiritual kin work: Orthodoxy, ivf, and the moral economy of motherhood in greece

Bringing gender and kinship studies together with an anthropology of religion, in this article I demonstrate how urban Greek couples and clinical practitioners in the middle 1990s proceeded with in vitro fertilization (IVF) in the absence of government regulations, and did so with reference to cultural beliefs and social relations consistent with Greek Orthodox religious practice. Drawing on ethnographic observations at an Athens IVF clinic as well as on interviews with former patients, I argue that Athenian women, in particular, engage IVF as a kind of spiritual kin work, normalizing the use of medical techniques with reference to ideologies of motherhood that treat it as a woman’s moral achievement and as a source of womanly suffering. Since the period of ethnographic research described here, and despite disapproval of the Greek Orthodox Church, legislation regulating the use of IVF and other methods of medically assisted reproduction has become law. This article reconciles how the Church can officially reject medically assisted means of reproduction that Athenian users have normalized with reference to spiritual beliefs and practices.     

Conscience claims,metaphysics, and avoiding an LGBT eugenic

Novel assisted reproductive technologies (ART) are poised to present our society with strange new ethical questions, such as whether lesbian, gay, bisexual, and transgender (LGBT) couples should be allowed to produce children biologically related to both parents, or whether trans‐women who want to experience childbirth should be allowed to receive uterine transplants. Clinicians opposed to offering such technologies to LGBT couples on moral grounds are likely to seek legal shelter through the conscience clauses enshrined in U.S. law. This paper begins by briefly discussing some novel ART on the horizon and noting that it is unclear whether current conscience clauses will permit fertility clinics to deny such services to LGBT individuals. A compromise approach to conscience is any view that sees the value of respecting conscience claims within limits. I describe and critique the constraints proposed in the recent work of Wicclair, NeJaime and Siegel as ultimately begging the question. My purpose is to strengthen their arguments by suggesting that in the controversial situations that elicit claims of conscience, bioethicists should engage with the metaphysical claims in play. I argue that conscience claims against LGBT individuals ought to be constrained because the underlying metaphysic—that God has decreed the LGBT lifestyle to be sinful—is highly implausible from the perspective of a naturalized metaphysic, which ought to be the lens through which we evaluate conscience claims.     

Sperm,Clinics, and Parenthood

In this article I examine a recent approach to regulating assisted reproduction, whereby use of some kind of medical intervention ‘triggers’ laws governing legal parenthood that are more favourable to intending parents and sperm providers. I argue that although perhaps an improvement on the previous legal framework, these laws are problematic for three important reasons. First, they are prone to violating parental rights and unjustly imposing substantial burdens on individuals. Second, they are discriminatory. Third, even if we take a pragmatic approach to the question of parenthood in these cases, these laws fail to properly consider the welfare interests of children. Finally, I conclude by showing that my argument does not entail adopting a laissez‐fair attitude to conception using third‐party sperm.     

Assisted Dying & Disability

This article explores at least two dominant critiques of assisted dying from a disability rights perspective. In spite of these critiques, I conclude that assisted dying ought to be permissible. I arrive at the conclusion that if we respect and value people with disabilities, we ought to permit assisted dying. I do so in the following manner. First, I examine recent changes in legislation that have occurred since the Royal Society of Canada Expert Panel on End‐of‐Life Decision‐Making report, published in this journal. I suggest that these changes are likely to only strengthen opposition to assisted dying from disability rights activists and people with disabilities. Second, I focus on respect for people with disabilities and in particular, respect for their autonomy and decision‐making abilities. Third, I explore the opposition to assisted dying that focuses on risk and the vulnerability of people with disabilities. Here I suggest that this risk ought not to be of special concern. Ultimately, I conclude that upholding respect for the disabled requires the legalization of assisted dying, rather than the denial of access in a misguided effort to protect people with disabilities.     

Orphaned at conception: the uncanny offspring of embryos

A number of advances in assisted reproduction have been greeted by the accusation that they would produce children 'without parents'. In this paper I will argue that while to date these accusations have been false, there is a limited but important sense in which they would be true of children born of a reproductive technology that is now on the horizon. If our genetic parents are those individuals from whom we have inherited 50% of our genes, then, unlike in any other reproductive scenario, children who were conceived from gametes derived from stem cell lines derived from discarded IVF embryos would have no genetic parents! This paper defends this claim and investigates its ethical implications. I argue that there are reasons to think that the creation of such embryos might be morally superior to the existing alternatives in an important set of circumstances.     

Two kinds of physician‐assisted death

I argue that the concept ‘physician‐assisted suicide’ covers two procedures that should be distinguished: giving someone access to humane means to end his own life, and taking co‐responsibility for the safe and effective execution of that plan. In the first section I explain the distinction, in the following sections I show why it is important. To begin with I argue that we should expect the laws that permit these two kinds of ‘assistance’ to be different in their justificatory structure. Laws that permit giving access only presuppose that the right to self‐determination implies a right to suicide, but laws that permit doctors to take co‐responsibility may have to appeal to a principle of mercy or beneficence. Actually this difference in justificatory structure can to some extent be found in existing regulatory systems, though far from consistently. Finally I argue that if one recognizes a right to suicide, as Oregon and other American states implicitly do, and as the European Court of Human Rights has recently done explicitly, one is committed to permit the first kind of ‘assistance’ under some conditions.     

Displayed Objects, Indigenous Identities, and Public Pedagogy

In this article, I describe how one group of student examines indigenous identity formation as dynamic and open to reinterpretation. Drawing on field observations and interviews with students in a 16-month ethnographic study, I examine how one group of students worked toward understanding how indigenous identity was determined by curatorial authority and historically defined museum practices. I argue that students can question the traditional pedagogical conceptions of indigenous culture that ought to be reconsidered within the public museum, and that working to historicize such conceptions makes more explicit student knowledge production of identity.     

RACIST APPEARANCE STANDARDS AND THE ENHANCEMENTS THAT LOVE THEM: NORMAN DANIELS AND SKIN‐LIGHTENING COSMETICS

Darker skin correlates with reduced opportunities and negative health outcomes. Recent discoveries related to the genes associated with skin tone, and the historical use of cosmetics to conform to racist appearance standards, suggest effective skin‐lightening products may soon become available. This article examines whether medical interventions of this sort should be permitted, subsidized, or restricted, using Norman Daniels's framework for determining what justice requires in terms of protecting health. I argue that Daniels's expansive view of the requirements of justice in meeting health needs offers some support for recognizing a societal obligation to provide this kind of ‘enhancement,’ in light of the strong connections between skin tone and health outcomes. On balance, however, Daniels's framework offers compelling reasons to reject insurance coverage for skin‐lightening medical interventions, including the likely ineffectiveness of such technologies in mitigating racial health disparities, and the danger that covering skin‐lightening enhancements would undermine public support for cooperative schemes that protect health. In fact, justice may require limiting access to these technologies because of their potential to exacerbate the negative effects of racism.     

Improving ovarian stimulation protocols for IVF in baboons: lessons from humans and rhesus monkeys

The aim of this review paper is to provide a scientific basis for the development of ovarian stimulation (OS) protocols for in vitro fertilization (IVF) in baboons. Firstly, the evidence available regarding OS for assisted reproduction in baboons is reviewed based on available published data, assessed by a Pub Med search of papers published between 1970 and 2008 using the following key words: baboon, assisted reproduction, IVF, embryo, oocyte. Secondly, we discuss how state-of-the-art or potentially new OS protocols used in humans and in rhesus monkeys may offer guidance for the development of standardized and reliable OS protocols for IVF in baboons. Based on this review and discussion, we conclude that more randomized trials are needed to improve standardization of OS protocols for IVF in baboons with respect to gonadotrophin type, dose, duration of stimulation, ultrasound monitoring, and time interval between ovulation trigger and oocyte retrieval.     

Compulsory moral bioenhancement should be covert

Some theorists argue that moral bioenhancement ought to be compulsory. I take this argument one step further, arguing that if moral bioenhancement ought to be compulsory, then its administration ought to be covert rather than overt. This is to say that it is morally preferable for compulsory moral bioenhancement to be administered without the recipients knowing that they are receiving the enhancement. My argument for this is that if moral bioenhancement ought to be compulsory, then its administration is a matter of public health, and for this reason should be governed by public health ethics. I argue that the covert administration of a compulsory moral bioenhancement program better conforms to public health ethics than does an overt compulsory program. In particular, a covert compulsory program promotes values such as liberty, utility, equality, and autonomy better than an overt program does. Thus, a covert compulsory moral bioenhancement program is morally preferable to an overt moral bioenhancement program.     

Medical Need,Equality, and Uncertainty

Many hold that distributing healthcare according to medical need is a requirement of equality. Most egalitarians believe, however, that people ought to be equal on the whole, by some overall measure of well‐being or life‐prospects; it would be a massive coincidence if distributing healthcare according to medical need turned out to be an effective way of promoting equality overall. I argue that distributing healthcare according to medical need is important for reducing individuals' uncertainty surrounding their future medical needs. In other words, distributing healthcare according to medical need is a natural feature of healthcare insurance; it is about indemnity, not equality.     

Eavesdropping foragers use level of collective commotion as public information to target high quality patches

Public information offers a valuable means for social foragers to determine the relative quality of foraging patches. Despite much evidence that foragers use public information based on others’ feeding behavior, no experiments have examined whether foragers might use public information based on others’ competitive behavior, particularly the collective commotion that can be generated by aggregations. Such commotion could potentially provide a rich source of public information: as foragers compete in a patch with an especially high value resource, their heightened competition intensity could enable eavesdropping foragers to target this superior patch, based simply on its higher level of collective commotion. To test the hypothesis that the level of collective commotion is used as public information by eavesdropping foragers I conducted field experiments on terrestrial hermit crabs Coenobita compressus. These animals engage in collective competitive interactions in foraging patches for food and shells, generating variable levels of commotion across different quality patches. By experimentally manipulating the level of collective commotion in sham aggregations in the wild I show that a higher level of commotion is exploited by eavesdropping foragers to differentially target more valuable patches. Broadly, these results highlight an underappreciated significance of competitive by‐products and higher‐ order collective pheno mena as forms of public information for foragers.     

REPRODUCTIVE TOURISM AND THE QUEST FOR GLOBAL GENDER JUSTICE

Reproductive tourism is a manifestation of a larger, more inclusive trend toward globalization of capitalist cultural and material economies. This paper discusses the development of cross‐border assisted reproduction within the globalized economy, transnational and local structural processes that influence the trade, social relations intersecting it, and implications for the healthcare systems affected. I focus on prevailing gender structures embedded in the cross‐border trade and their intersection with other social and economic structures that reflect and impact globalization. I apply a social connection model of responsibility for unjust outcomes and consider strategies to counter structural injustices embedded in this industry. The concluding section discusses policy reforms and proposals for collaborative action to preclude further injustices and extend full human rights to all.     

Splitting the Difference? Principled Compromise and Assisted Dying

Compromise on moral matters attracts ambivalent reactions, since it seems at once laudable and deplorable. When a hotly‐contested phenomenon like assisted dying is debated, all‐or‐nothing positions tend to be advanced, with little thought given to the desirability of, or prospects for, compromise. In response to recent articles by Søren Holm and Alex Mullock, in this article I argue that principled compromise can be encouraged even in relation to this phenomenon, provided that certain conditions are present (which I suggest they are). In order to qualify as appropriately principled, the ensuing negotiations require disputants to observe three constraints: they should be suitably reflective, reliable and respectful in their dealings with one another. The product that will result from such a process will also need to split the difference between the warring parties. In assisted dying, I argue that a reduced offence of ‘compassionate killing’ can achieve this. I acknowledge, however, that splitting the difference can induce splitting headaches, as there remain certain questions to be answered. Hopefully, however, sufficient work is done here to defend attempts to occupy the middle ground, whether these relate to assisted dying specifically or to other disputed moral matters.     

Insurance coverage and incentives for weight loss among adults with metabolic syndrome

Objective: To describe how insured adults with metabolic syndrome respond to various options for insurance coverage and financial incentives for weight management. Methods and Procedures: Insured adults meeting the criteria for the metabolic syndrome were randomly identified through automated medical records and invited to participate in a telephone‐based survey of the acceptability of various weight management programs—with different financial incentives and insurance coverage options—in a health maintenance organization. Multivariable logistic regression models were used to test the relationship between participant characteristics and the odds of being motivated by incentives. Results: One hundred and fifty‐three adults with the metabolic syndrome completed the survey (i.e., 79% of telephone contacts). A hypothetical increase in insurance coverage from 10 to 100% led to a threefold increase among women and a sevenfold increase among men in the proportion reporting they were “very interested” in enrolling in a weight management program within the next 30 days. Most participants (76% of women and 57% of men) supported a health plan–sponsored financial incentive program tied to weight loss, and 41% believed such a program would motivate them to lose weight. The mean financial incentive proposed for a 15‐pound weight loss was $591 (median: $125). Discussion: Although weight loss is an effective treatment for metabolic syndrome, standard health insurance rarely covers intensive behavioral treatment. The results of this study suggest that providing full insurance coverage and financial incentives for weight management increases the interest in participating in obesity treatment programs. Further research should determine how full coverage and incentives affect participation rates, long‐term body weight changes, and costs.     

Sex selection in India: Why a ban is not justified

When widespread use of sex‐selective abortion and sex selection through assisted reproduction lead to severe harms to third parties and perpetuate discrimination, should these practices be banned? In this paper I focus on India and show why a common argument for a ban on sex selection fails even in these circumstances. I set aside a common objection to the argument, namely that women have a right to procreative autonomy that trumps the state's interest in protecting other parties from harm, and argue against the ban on consequentialist grounds. I perform a pairwise comparative analysis of sex selection and its plausible alternatives and argue that that the ban fails to improve the state of affairs relative to a scenario without a ban. The ban makes the situation worse, especially for mothers and their daughters. India should therefore repeal its ban on sex selection.