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Ethics of Posthumous Reproduction
Abstract
This chapter explores the ethical issues with posthumous assisted reproduction for individuals who already have frozen gametes or embryos and for individuals requiring postmortem gamete retrieval. Relying on the core ethical principles of justice, beneficence/nonmaleficence, and autonomy, I analyze some of the key ethical issues raised by posthumous assisted reproduction. I then examine who (e.g., surviving partner, surviving parents, third party, etc.) should be permitted to request PAR. I draw heavily on the guidelines issued by the ethics committees of the American Society for Reproductive Medicine (ASRM) and the European Society of Human Reproduction and Embryology (ESHRE).
... The 2013 opinion stated, in short, "Posthumous gamete (sperm or oocyte) procurement and reproduction are ethically justifiable if written documentation from the deceased authorizing the procedure is available." They further clarified that "in the absence of written documentation from the decedent, programs open to considering requests for posthumous gamete procurement or reproduction should only do so when such requests are initiated by the surviving spouse or life partner" [9]. The pioneering policy work at Cornell University and the guidelines issued by the Ethics Committee of the American Society for Reproductive Medicine provide a framework for U.S. hospitals to create bespoke policies on post-mortem sperm retrieval. ...
The scholarly discussion of posthumous reproduction (PHR) focuses on informed consent and the welfare of the future child, for the most part overlooking cultural differences between societies. Based on a cross-cultural comparison of legal and regulatory documents, analysis of pivotal cases and study of scholarly and media discussions in Israel and Germany, this paper analyses the relevant ethical and policy issues, and questions how cultural differences shape the practice of PHR. The findings challenge the common classifications of PHR by highlighting the gender perspective and adding brain-dead pregnant women to the debate. Based on this study’s findings, four neglected cultural factors affecting social attitudes towards PHR are identified: (i) the relationship between the pregnant woman and her future child; (ii) what constitutes the beginning of life; (iii) what constitutes dying; and (iv) the social agent(s) seeking to have the future child. The paper argues that PHR can be better understood by adding the gender and margins-of-life perspectives, and that future ethical and practical discussions of this issue could benefit from the criteria emerging from this cross-cultural analysis.
The feasibility of posthumous reproduction when the surviving partner is female has brought to light many ethical, moral, social, and legal issues. This review aims to summarize these issues and to assist clinicians who may be faced with such requests. A question list, used for health technologies assessment, was utilized in a question-answer approach as the review methodology. Of the 1,208 publications identified through a comprehensive literature search in biomedical, psychological, and ethical databases, 31 articles included arguments related to one or more questions from the predefined question set. Key stakeholders identified include the deceased, the requesting party, the resultant child, the physician, and society. Key ethical issues relevant to posthumous reproduction include the four traditional pillars of medical ethics-autonomy, beneficence, nonmaleficence, justice-as well as the stakeholders' rights and sociocultural attitudes. The ethical framework formulated by these issues has been incorporated in a clinical ethics decision-making tool that could prove useful to clinicians and decision makers.
Copyright 2015 The Journal of Clinical Ethics. All rights reserved.
Objective:
To identify and analyze existing posthumous sperm procurement (PSP) protocols in order to outline central themes for institutions to consider when developing future policies.
Design:
Qualitative content analysis.
Setting:
Large academic institutions across the United States.
Patient(s) n/a intervention(s):
We performed a literature search and contacted 40 institutions to obtain nine full PSP protocols. We then performed a content analysis on these policies to identify major themes and factors to consider when developing a PSP protocol.
Main outcome measure(s):
Presence of a PSP policy.
Result(s):
We identified six components of a thorough PSP protocol: Standard of Evidence, Terms of Eligibility, Sperm Designee, Restrictions on Use in Reproduction, Logistics, and Contraindications. We also identified two different approaches to policy structure. In the Limited Role approach, institutions have stricter consent requirements and limit their involvement to the time of procurement. In the Family-Centered approach, substituted judgment is permitted but a mandatory wait period is enforced before sperm use in reproduction.
Conclusion(s):
Institutions seeking to implement a PSP protocol will benefit from considering the six major building blocks of a thorough protocol and where they would like to fall on the spectrum from a Limited Role to a Family-Centered approach.
This article analyses the different ethical aspects of posthumous assisted reproduction. Two situations are distinguished:
cases in which the gametes or embryos are used by the surviving partner and cases in which the gametes or embryos are made
available for third persons. The moral evaluation of the procedure depends on whether the act is restricted to the existing
parental project. A major difficulty for the moral evaluation is the inconclusiveness of the empirical data on the psychosocial
development of children born after this procedure. The Task Force concluded that posthumous reproduction by a partner is acceptable
if the following conditions are met: written consent has been given by the deceased person, the partner received extensive
counselling and a minimum waiting period of 1 year is imposed before a treatment can be started. For use by third parties,
the usual conditions for gamete and embryo donation apply.
Conception of a child using cryopreserved sperm from a deceased man is generally considered ethically sound provided explicit consent for its use has been made, thereby protecting the man's autonomy. When death is sudden (trauma, unexpected illness), explicit consent is not possible, thereby preventing posthumous sperm procurement (PSP) and conception according to current European Society of Human Reproduction and Embryology and the American Society for Reproductive Medicine guidelines. Here, we argue that autonomy of a deceased person should not be considered the paramount ethical concern, but rather consideration of the welfare of the living (widow and prospective child) should be the primary focus. Posthumous conception can bring significant advantages to the widow and her resulting child, with most men supporting such practice. We suggest that a deceased man can benefit from posthumous conception (continuation of his ‘bloodline’, allowing his widow's wishes for a child to be satisfied), and has a moral duty to allow his widow access to his sperm, if she so wishes, unless he clearly indicated that he did not want children when alive. We outline the arguments favouring presumed consent over implied or proxy consent, plus practical considerations for recording men's wishes to opt-out of posthumous conception.
Objective
To report results of analysis of in vitro fertilization (IVF) users' choices regarding the potential use of their surplus cryopreserved embryos for posthumous assisted reproduction (PAR).
Design
Examination of signed consent forms.
Setting
The study was carried out at the public IVF clinic of a university medical center.
Patient(s)
A total of 498 individuals who had signed consent forms for cryopreservation of surplus embryos.
Intervention(s)
Content analysis of consent form.
Main Outcome Measure(s)
Agreement to PAR; importance of appropriate counseling within the consent process.
Result(s)
Approximately 68% of individuals consented to the use of surplus embryos for embryologist training and improvement of assisted reproductive techniques, and 56% consented to the use of surplus embryos in a research project; 73.5% of men and 61.8% of women agreed to leave their cryopreserved embryos to their partners for reproductive use in the event of their death.
Conclusion(s)
Our results demonstrate that a majority of both men and women agree to leave their frozen embryos to their partners for PAR in a “real life” context, i.e., in which they were required to provide consent for this prospective option. PAR involves complex issues, including the psychologic aspects of initiating a pregnancy while mourning the loss of a loved one or the effect on the prospective child. We argue that in light of the acceptability of PAR—as demonstrated by our results—further research is required regarding how to best counsel and inform IVF users about the choices they are making in this context, to ensure that their consent for PAR is in fact well informed.
Policy and medical decision-making has been hindered by the absence of reliable data on attitudes toward having one's own gametes retrieved posthumously and used to produce a child in the event of an untimely death. The purpose of this study is to directly and empirically examine whether the presumption against consent is justified in the case of posthumous gamete retrieval following sudden death. Respondents (N = 2064) were contacted using a random-digit dialing method that gave every household telephone in the continental United States an equal probability of being contacted, and were asked: "Suppose you were to experience an early death and your spouse wanted to have a biological child with you. Would you or would you not want your spouse to be able to use your sperm/eggs following your death to have a child with you?" Among reproductive age respondents (18-44 years), 70% of males and 58% of females wanted their spouse to be able to use their gametes and, for the most part, attitudes were fairly consistent across demographic characteristics. Religiosity was the best predictor of attitudes-those who described themselves as more religious were less likely to desire posthumous gamete retrieval-but the majority (58%) of respondents who were very religious approved of retrieval. Overall, these data indicate that abandoning the prevailing presumption against consent in favor of a presumption of consent on the part of the deceased will result in the deceased's wishes being honored two and three times more often for females and males, respectively. Three main arguments against a presumption of consent in this context are discussed: autonomy of the deceased, conflict of interest, and the decision-making capacity of a grieving spouse.
A multiple segment factorial vignette was used with a probability sample of 857 U.S. households to assess the effects of contextual variables on attitudes toward posthumous reproduction using the cryopreserved gametes of a deceased partner. Attitudes were affected in predictable directions by marital status, gender of the deceased individual, disposition of the deceased's parents, and the deceased's wishes. In addition, respondents who identified more closely with their chosen religion tended to perceive posthumous conception as less appropriate and those who had never had children attributed a greater degree of obligation to assist on the part of medical professionals.
Current, ongoing national surveys do not include questions about end-of-life (EOL) issues. In particular, population-based data are lacking regarding the factors associated with advance directive completion.
To characterize U.S. adults who did and did not have an advance directive and examine factors associated with their completion, such as the presence of a chronic condition and regular source of health care.
Data were analyzed in 2013 from adults aged 18 years and older who participated in the 2009 or 2010 HealthStyles Survey, a mail panel survey designed to be representative of the U.S. population. Likelihood ratio tests were used to examine the associations between advance directive completion and demographic and socioeconomic variables (education, income, employment status); presence of a chronic condition; regular source of health care; and self-reported EOL concerns or discussions. Multiple logistic regression analyses identified independent predictors related to advance directive completion.
Of the 7946 respondents, 26.3% had an advance directive. The most frequently reported reason for not having one was lack of awareness. Advance directive completion was associated with older age, more education, and higher income and was less frequent among non-white respondents. Respondents with advance directives also were more likely to report having a chronic disease and a regular source of care. Advance directives were less frequent among those who reported not knowing if they had an EOL concern.
These data indicate racial and educational disparities in advance directive completion and highlight the need for education about their role in facilitating EOL decisions.
To measure public attitudes toward posthumous reproduction.
Cross-sectional study.
Electronic survey.
A total of 1,049 men and women living in the United States between the ages of 18 and 75 years.
Multiple-choice questionnaire.
Descriptive statistics regarding support for posthumous reproduction, such as regarding emergency harvesting of gametes, and attitudes toward consent; multivariable analyses of demographic and personal experiences associated with support for posthumous reproduction.
Results showed that 47.8% supported and 31.1% opposed retrieving gametes from men, and 42.7% supported and 35.9% opposed retrieving gametes from women. The remainder was undecided. Among supporters, 69.8% believed prior consent from the deceased was required. Support was positively associated with younger age, higher education, higher income, Democratic political party affiliation, history of infertility, and currently attempting conception. Gender, religion, race, and region of the country were not associated with support. Organ donors and those who support IVF were more likely to support posthumous reproduction (odds ratio [95% confidence interval] 1.68 [1.19-2.38] and 12.30 [6.56-23.04], respectively). Most respondents were initially unfamiliar with posthumous reproduction.
Almost 50% of the general population support posthumous reproduction in men and women. The majority favored prior consent from the deceased. These data caution against emergency gamete harvesting without prior consent.
To study attitudes about posthumous assisted reproduction (PAR) in individuals presenting for assisted reproduction, to examine the degree of concordance of attitudes within couples, and to determine whether individuals can accurately predict the attitudes of their intimate partners.
Cross sectional survey.
University-based fertility center.
One hundred six couples presenting for an initial fertility evaluation.
Anonymous survey completed independently by each partner.
1) individual attitudes about PAR, 2) the rate of concordance in attitudes within couples, and 3) the ability of individuals to predict their partner's attitudes.
Approximately 78% of individuals stated they would permit PAR. Couples expressed concordant attitudes about 75% of the time. Statistically, women and men were equivalent in correctly predicting their partner's attitudes (79% vs. 71%).
Although most individuals presenting for fertility treatment would agree to PAR, there was also a notable portion that stated that they would not consent with the process. Although most couples had concordant attitudes, discordance was also prevalent. Individuals often, but not always, were able to predict their partner's attitudes about PAR.
Assisted reproductive technologies are increasingly more present in our everyday life: from classical sperm/egg donation or in vitro fertilization to newer, more controversial methods such as surrogate motherhood, male pregnancies or posthumous sperm procurement. Every year, new concepts are emerging in this field and the medical world is not always prepared to deal with them.
The greatest problem of using posthumous sperm procurement as an assisted reproductive method resides in analyzing consent related. An extensive research of the scientific literature revealed eight possible situations which we will present and analyze in this article.
By analyzing consent related issues we present a decision making algorithm for posthumous sperm procurement.
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