Assisted Reproduction and Distributive Justice

The Canadian province of Quebec recently amended its Health Insurance Act to cover the costs of In Vitro Fertilization (IVF). The province of Ontario recently de‐insured IVF. Both provinces cited cost‐effectiveness as their grounds, but the question as to whether a public health insurance system ought to cover IVF raises the deeper question of how we should understand reproduction at the social level, and whether its costs should be a matter of individual or collective responsibility. In this article I examine three strategies for justifying collective provisions in a liberal society and assess whether public reproductive assistance can be defended on any of these accounts. I begin by considering, and rejecting, rights‐based and needs‐based approaches. I go on to argue that instead we ought to address assisted reproduction from the perspective of the contractarian insurance‐based model for public health coverage, according to which we select items for inclusion based on their unpredictability in nature and cost. I argue that infertility qualifies as an unpredictable incident against which rational agents would choose to insure under ideal conditions and that assisted reproduction is thereby a matter of collective responsibility, but only in cases of medical necessity or inability to pay. The policy I endorse by appeal to this approach is a means‐tested system of coverage resembling neither Ontario nor Quebec's, and I conclude that it constitutes a promising alternative worthy of serious consideration by bioethicists, political philosophers, and policy‐makers alike.     

Exposing Silence as Cultural Censorship: A Brazilian Case

In this article I assert that in focusing on salient discourses, contested cultural domains, and public forms of conflict and power, cultural and linguistic anthropologists, and other social scientists, have overlooked the significance of communal forms of silence in shaping the social and political landscape. I argue that such customary silences constitute "cultural censorship," which, unlike state-sponsored censorship, is practiced in the absence of explicit coercion or enforcement. Although practiced by different and opposed groups, cultural censorship tends to be constituted through, and circumscribed by. the political interests of dominant groups. In this article, which is based on ethnographic research in Rio de Janeiro. I analyze a case of cultural censorship by examining the customary silence surrounding the subject of racism in Brazil. By emphasizing the phenomenology of cultural censorship among poor Brazilians of African descent. 1 argue that silence must not be conflated with, and does not preclude the existence of. non-hegemonic consciousness, [silence, cultural censorship, consciousness, Brazil, racism]     

Drawing the line on in vitro gametogenesis

In vitro gametogenesis (IVG) might offer numerous research and clinical benefits. Some potential clinical applications of IVG, such as allowing opposite-sex couples experiencing infertility to have genetically related children, have attracted support. Others, such as enabling same-sex reproduction and solo reproduction, have attracted significantly more criticism. In this paper, we examine how different ethical principles might help us to draw lines and distinguish between ethically desirable and undesirable uses of IVG. We discuss the alleged distinction between therapeutic and non-therapeutic uses of assisted reproduction in the context of IVG, and show how it is both problematic to apply in practice and theoretically dubious. We then discuss how the ethical principles of reproductive justice and beneficence apply to IVG for opposite-sex reproduction, same-sex reproduction, and solo reproduction. We suggest that these principles generate strong reasons for the use of IVG for opposite-sex and same-sex reproduction, but not for solo reproduction.     

'The good of the child'

Warnock, chair of Britain's Committee of Inquiry into Human Fertilisation and Embryology, discusses the implications of the "artificial family" for children born through the use of reproductive technologies. She considers both treatment of infertility and the possible use of assisted reproduction to enable persons other than infertile couples, such as single persons and homosexuals, to have children. Warnock has found that emphasis has been placed on the wants and well-being of the adult(s) involved, and that the "good of the child" is a "wide and vague concept, widely invoked, not always plausibly." She is particularly concerned about children born as a result of the delayed implantation of frozen embryos, AID children who are deceived about their origins, and children born of surrogate pregnancies. She recommends that a detailed study of existing "artificial family" children be conducted to aid public policy decisions on assisted reproduction.     

In whose interest? Policy and politics in assisted reproduction

This paper interprets the British legislative process that initiated the first comprehensive national regulation of embryo research and fertility services and examines subsequent efforts to restrain the assisted reproduction industry. After describing and evaluating British regulatory measures, I consider successive failures to control the assisted reproduction industry in the US. I discuss disparities between UK and US regulatory initiatives and their bearing on regulation in other countries. Then I turn to the political and social structures in which the assisted reproduction industry is embedded. I argue that regulatory bodies are seldom neutral arbiters. They tend to respond most readily to special interests and neglect strategies that could more effectively meet the health needs of the people they represent. Neither national nor international bodies have aggressively pursued policies to harness the industry, reduce infertility rates, or meet the needs of people whose fertility is threatened by substandard healthcare and environmental neglect. In conclusion, I consider recent initiatives by activist groups to mount an alternative response to the industry's current practices and build a transnational reproductive justice movement.     

Role of oxidative stress in female reproduction

In a healthy body, ROS (reactive oxygen species) and antioxidants remain in balance. When the balance is disrupted towards an overabundance of ROS, oxidative stress (OS) occurs. OS influences the entire reproductive lifespan of a woman and even thereafter (i.e. menopause). OS results from an imbalance between prooxidants (free radical species) and the body's scavenging ability (antioxidants). ROS are a double-edged sword – they serve as key signal molecules in physiological processes but also have a role in pathological processes involving the female reproductive tract. ROS affect multiple physiological processes from oocyte maturation to fertilization, embryo development and pregnancy. It has been suggested that OS modulates the age-related decline in fertility. It plays a role during pregnancy and normal parturition and in initiation of preterm labor. Most ovarian cancers appear in the surface epithelium, and repetitive ovulation has been thought to be a causative factor. Ovulation-induced oxidative base damage and damage to DNA of the ovarian epithelium can be prevented by antioxidants. There is growing literature on the effects of OS in female reproduction with involvement in the pathophsiology of preeclampsia, hydatidiform mole, free radical-induced birth defects and other situations such as abortions. Numerous studies have shown that OS plays a role in the pathoysiology of infertility and assisted fertility. There is some evidence of its role in endometriosis, tubal and peritoneal factor infertility and unexplained infertility. This article reviews the role OS plays in normal cycling ovaries, follicular development and cyclical endometrial changes. It also discusses OS-related female infertility and how it influences the outcomes of assisted reproductive techniques. The review comprehensively explores the literature for evidence of the role of oxidative stress in conditions such as abortions, preeclampsia, hydatidiform mole, fetal embryopathies, preterm labour and preeclampsia and gestational diabetes. The review also addresses the growing literature on the role of nitric oxide species in female reproduction. The involvement of nitric oxide species in regulation of endometrial and ovarian function, etiopathogenesis of endometriosis, and maintenance of uterine quiescence, initiation of labour and ripening of cervix at parturition is discussed. Complex interplay between cytokines and oxidative stress in the etiology of female reproductive disorders is discussed. Oxidant status of the cell modulates angiogenesis, which is critical for follicular growth, corpus luteum formation endometrial differentiation and embryonic growth is also highlighted in the review. Strategies to overcome oxidative stress and enhance fertility, both natural and assisted are delineated. Early interventions being investigated for prevention of preeclampsia are enumerated. Trials investigating combination intervention strategy of vitamin E and vitamin C supplementation in preventing preeclampsia are highlighted. Antioxidants are powerful and there are few trials investigating antioxidant supplementation in female reproduction. However, before clinicians recommend antioxidants, randomized controlled trials with sufficient power are necessary to prove the efficacy of antioxidant supplementation in disorders of female reproduction. Serial measurement of oxidative stress biomarkers in longitudinal studies may help delineate the etiology of some of the diosorders in female reproduction such as preeclampsia.     

Middle Eastern masculinities in the age of new reproductive technologies: male infertility and stigma in Egypt and Lebanon

Worldwide, male infertility contributes to more than half of all cases of childlessness; yet, it is a reproductive health problem that is poorly studied and understood. This article examines the problem of male infertility in two Middle Eastern locales, Cairo, Egypt, and Beirut, Lebanon, where men may be at increased risk of male infertility because of environmental and behavioral factors. It is argued that male infertility may be particularly problematic for Middle Eastern men in their pronatalist societies; there, both virility and fertility are typically tied to manhood. Thus, male infertility is a potentially emasculating condition, surrounded by secrecy and stigma. Furthermore, the new reproductive technology called intracytoplasmic sperm injection (ICSI), designed specifically to overcome male infertility, may paradoxically create additional layers of stigma and secrecy, due to the complex moral and marital dilemmas associated with Islamic restrictions on third-party donation of gametes.     

The appeal to nature implicit in certain restrictions on public funding for assisted reproductive technology

Certain restrictions on public funding for assisted reproductive technology (ART) are articulated and defended by recourse to a distinction between medical infertility and social infertility. We propose that underlying the prioritization of medical infertility is a vision of medicine whose proper role is to restore but not to improve upon nature. We go on to mark moral responses that speak of investments many continue to make in nature as properly an object of reverence and gratitude and therein (sometimes) a source of moral guidance. We draw on the work of Ludwig Wittgenstein in arguing for the plausibility of an appeal to nature in opposition to the charge that it must contain a logical fallacy. We also invite consideration of the moral plausibility of some appeal to nature. Finally, we examine what follows in the case of ART. Should medicine respect as natural limits that should not be overcome: the need for a man and a woman in reproduction; menopause; and even declining fertility with age? We must first ask ourselves to what degree we should defer to nature in the conduct of medicine, at least in the particular if not the general case. This will involve also asking ourselves what we think is natural and in what instances and spirit might we defy nature. Divergent opinions and policies concerning who should receive ART treatment and public funding are more easily understood in view of the centrality, complexity and fundamental nature of these questions.     

Environmental chemical mediated male reproductive toxicity: Drosophila melanogaster as an alternate animal model

Industrialization and indiscriminate use of agrochemicals have increased the human health risk. Recent epidemiological studies raised a concern for male reproduction given their observations of reduced sperm counts and altered semen quality. Interestingly, environmental factors that include various metals, pesticides and their metabolites have been causally linked to such adversities by their presence in the semen at levels that correlate to infertility. The epidemiological observations were further supported by studies in animal models involving various chemicals. Therefore, in this review, we focused on male reproductive toxicity and the adverse effects of different environmental chemicals on male reproduction. However, it is beyond the scope of this review to provide a detailed appraisal of all of the environmental chemicals that have been associated with reproductive toxicity in animals. Here, we provided the evidence for reproductive adversities of some commonly encountered chemicals (pesticides/metals) in the environment. In view of the recent thrust for an alternate to animal models in research, we subsequently discussed the contributions of Drosophila melanogaster as an alternate animal model for quick screening of toxicants for their reproductive toxicity potential. Finally, we emphasized the genetic and molecular tools offered by Drosophila for understanding the mechanisms underlying the male reproductive toxicity.     

The effects of density-dependent offspring mortality on the synchrony of reproduction

Mortality rates often depend on the size of a population. Using ideal free theory to model the optimal timing of reproduction in model populations, I considered how the specific relationship between density-dependent offspring mortality and population size affects the optimal temporal distribution of reproduction. The results suggest that the specific form of the relationship between density-dependent mortality and the number of offspring produced determines the degree to which reproduction within a population is synchronous. Specifically, reproductive synchrony decreases as density-dependent mortality becomes increasingly inversely related to the number of offspring produced and is highest when density-dependent mortality is directly density-dependent. These findings support the suggestion that predation pressure selects for greater reproductive synchrony in species where mortality is directly density-dependent, but does not affect the timing of reproduction in species with density-independent rates of mortality. This revised version was published online in July 2006 with corrections to the Cover Date.     

EGG FREEZING: A BREAKTHROUGH FOR REPRODUCTIVE AUTONOMY?

This article describes the relatively new technology of freezing human eggs and examines whether egg freezing, specifically when it is used by healthy women as 'insurance' against age-related infertility, is a legitimate exercise of reproductive autonomy. Although egg freezing has the potential to expand women's reproductive options and thus may represent a breakthrough for reproductive autonomy, I argue that without adequate information about likely outcomes and risks, women may be choosing to freeze their eggs in a commercially exploitative context, thus undermining rather than expanding reproductive autonomy.     

Lawful Sinners: Reproductive Governance and Moral Agency Around Abortion in Mexico

The Catholic Hierarchy unequivocally bans abortion, defining it as a mortal sin. In Mexico City, where the Catholic Church wields considerable political and popular power, abortion was recently decriminalized in a historic vote. Of the roughly 170,000 abortions that have been carried out in Mexico City's new public sector abortion program to date, more than 60% were among self-reported Catholic women. Drawing on eighteen months of fieldwork, including interviews with 34 Catholic patients, this article examines how Catholic women in Mexico City grapple with abortion decisions that contravene Church teachings in the context of recent abortion reform. Catholic women consistently leveraged the local cultural, economic, and legal context to morally justify their abortion decisions against church condemnation. I argue that Catholic women seeking abortion resist religious injunctions on their reproductive behavior by articulating and asserting their own moral agency grounded in the contextual dimensions of their lives. My analysis informs conversations in medical anthropology on moral decision-making around reproduction and on local dynamics of resistance to reproductive governance. Moreover, my findings speak to the deficiencies of a feminist vision focused narrowly on fertility limitation, versus an expanded framework of reproductive justice that considers as well the need for conditions of income equality and structural supports to facilitate reproduction and parenting among women who desire to keep their pregnancies.     

Contemplating choice: attitudes towards intervening in human reproduction in Sri Lanka

To date, relatively little is known about the ethical, legal and social responses to recent advances in reproductive and genetic technology outside of Europe and North America. This article reports on a survey carried out among doctors (n?=?278) and medical students (n?=?1256) in Sri Lanka to find out more about their responses to novel interventions in human reproduction such as In-Vitro Fertilization, Pre-Implantation Genetic Diagnosis and genetic engineering. In the first part of the paper comparisons are drawn between this survey and a survey carried out in 1985 which also considered issues surrounding amniocentesis and therapeutic termination. The second part of the paper deals with more recent developments. The analysis reveals high levels of support for the use of new technologies in treating infertility and identifying genetic disorders. However, differences are apparent among the major religious communities represented in the sample and these are particularly in evidence in relation to pre-natal genetic diagnosis. An important theme throughout both surveys is the continuing tension surrounding State policy on termination of pregnancy and the implications this has for the development of screening and counseling services where genetic disorders are concerned.     

Human longevity and early reproduction in pre‐industrial Sami populations

Senescence is predicted to be associated with the intensity and timing of reproduction at an earlier age. Here, we examine the phenotypic association between reproduction and post‐reproductive survival in three pre‐industrial human populations that lived in Northern Scandinavia during 1640–1870. In both sexes longevity was independent of the total number of born or adult children, whereas early reproduction was negatively associated with the longevity of females and males. Our results thus do not support the view that reproductive investment as such has a negative impact on longevity, but suggest that survival costs are associated with the scheduling of reproduction. We discuss, however, an alternative point of view suggesting that less intense selection for early reproduction, extended parental care, and social structure allowing kin selection through the effects of close relatives are factors that have selected for the long post‐reproductive life span in humans.     

Contemplating choice: attitudes towards intervening in human reproduction in Sri Lanka

To date, relatively little is known about the ethical, legal and social responses to recent advances in reproductive and genetic technology outside Europe and North America. This article reports on a survey carried out among doctors (n=278) and medical students (n=1256) in Sri Lanka to find out more about their responses to novel interventions in human reproduction such as In-Vitro Fertilization, Pre-Implantation Genetic Diagnosis and genetic engineering. In the first part of the paper comparisons are drawn between this survey and a survey carried out in 1985 which also considered issues surrounding amniocentesis and therapeutic termination. The second part of the paper deals with more recent developments. The analysis reveals high levels of support for the use of new technologies in treating infertility and identifying genetic disorders. However, differences are apparent among the major religious communities represented in the sample and these are particularly in evidence in relation to prenatal genetic diagnosis. An important theme throughout both surveys is the continuing tension surrounding State policy and termination of pregnancy and the implications this has for the development of screening and counseling services where genetic disorders are concerned.     

Life history theory and human reproductive behavior

The purpose of this article is to develop a model of life history theory that incorporates environmental influences, contextual influences, and heritable variation. I argue that physically or psychologically stressful environments delay maturation and the onset of reproductive competence. The social context is also important, and here I concentrate on the opportunity for upward social mobility as a contextual influence that results in delaying reproduction and lowering fertility in the interest of increasing investment in children. I also review evidence that variation in life history strategies is influenced by genetic variation as well. Finally, I show that cultural shifts in the social control of sexual behavior have had differential effects on individuals predisposed to high- versus low-investment reproductive strategies.     

Abortion Rights along the Irish-English Border and the Liminality of Women’s Experiences

My research in European abortion laws and restrictions focuses on the migration of thousands of Irish women who travel to England each year to access safe and legal abortion services. This article is an investigation of the Irish-English border as a symbol for reproductive freedom and the new value systems in which Irish women participate when they cross its boundary. I provide a brief history of abortion law in the Republic of Ireland and Northern Ireland and emphasize a specific case in which border crossing was severely restricted for a young rape victim desiring an abortion. Additionally, my research examines women’s experiences of liminality as they cross the Irish-English border and the complex, conflicting emotions that they may feel as they travel abroad. In particular, I address a recent pro-choice initiative by a Dutch organization called Women on Waves, which sent a ship converted into a reproductive clinic to Dublin to provide services to Irish women. The ship, which has since sailed to Poland and Portugal to offer further assistance to women in countries with bans on abortion, complicates the notion of crossing concrete national lines as it moves throughout international waters.     

Reproductive tolerance in male primates: Old paradigms and new evidence

Within social groups of primates, males commonly compete over reproduction, but they may also rely on cooperation with other males. Theory suggests that it may be adaptive for male primates to tolerate some reproduction by other males if reproductive tolerance fosters cooperation, particularly that dominant males yield so‐called reproductive concessions to subordinates to entice their cooperation. We review four recent studies that claimed to have found evidence for reproductive concessions or similar forms of reproductive tolerance. However, upon critical reevaluation of their results, no study provides conclusive support for reproductive concessions as predicted by theoretical models. Yet two studies demonstrated a form of reproductive tolerance that cannot be explained by any of the existing models, and that seems to have evolved only in multi‐male, multi‐female societies with diverse strategic options for males. Our article provides guidance how to study this form of reproductive tolerance in the absence of a unifying model.