Anna Smajdor

In this paper, we report the results from an experimental reproductive ethics study exploring questions about reproduction and parenthood. The main finding in our study is that, while we may assume that everyone understands these concepts and their relationship in the same way, this assumption may be unwarranted. For example, we may assume that if ‘x is y’s father’, it follows that ‘y is x’s child’. However, the participants in our study did not necessarily agree that it does follow. This means, at the very least, that we need to make sure all parties in a debate have the same relationships in mind when talking about reproduction and parenthood. Moreover, it gives us reason to explore more carefully the conditions which support or undermine the connections between these concepts. This cannot come from purely theoretical reasoning, nor from empirical research alone, but from the alliance between the two.

Mitochondrial replacement therapy has been developed in order to prevent the transmission of mitochondrial mutations, yet it raises ethical concerns, particularly regarding the involvement of third-party DNA and the risks associated with donor procedures. This paper explores an alternative approach using synthetic DNA (synDNA) to construct mitochondrial organelles, thereby bypassing the need for donor oocytes and bypassing risks to donors. We argue that those who support mitochondrial replacement techniques as an ethically acceptable means of preventing the transmission of mitochondrial disease should consider the use of synthetic mitochondria as a preferable ethical alternative, should it prove technically viable. That this will be viable is more than we can demonstrate here. However, progress in synDNA technology suggests that it is not unreasonable to think that synthetic mitochondria creation is feasible, and perhaps even probable.

Neste artigo, comparamos as capacidades e limitações dos algoritmos de inteligência artificial e dos médicos humanos no contexto de recomendações terapêuticas. A literatura tem levantado preocupações éticas acerca da transparência, da responsabilização e da interpretabilidade dos algoritmos de IA no âmbito médico. A autonomia dos pacientes dificilmente será respeitada se as recomendações de tratamento forem opacas ou incompreensíveis. Os algoritmos de IA médica são programados para priorizar objetivos predefinidos que podem não estar alinhados com as preferências dos pacientes, podendo comprometer sua autonomia sem que eles tenham consciência disso. No entanto, médicos humanos frequentemente enfrentam desafios semelhantes, como a dependência de dados de ensaios clínicos cujos desfechos podem não ser plenamente compreendidos pelos pacientes. Concluímos que existem oportunidades, já no estágio de projeto, para incorporar considerações sobre a autonomia do paciente nos algoritmos de IA e para tornar explícitos aos usuários finais — tanto médicos quanto pacientes — esses objetivos e os eventuais pesos atribuídos a eles. Palavras-chave: Inteligência artificial. Autonomia. Alinhamento. Ética médica.

Lee argues that pronatalist policies in countries suffering from declining birth rates, such as South Korea, are ethically flawed.1 The ‘soft’ pronatalist policies Lee describes aim at persuading citizens to reproduce. For Lee, coercive pronatalist policies are so obviously unacceptable as not to merit consideration. However, we suggest that this is an issue that requires further analysis. When ethicists regard certain possibilities as not worth debating, we miss opportunities to examine the basis for our convictions. In short, it behoves us now and again to challenge our convictions, especially if they seem inconsistent in relation to other views we hold. By comparing coercive pronatalism with enforced military conscription, we can notice some inconsistencies. South Korea—which Lee discusses in her paper—enforces military service, as do Austria, Switzerland, Ukraine and Finland to name a few. Many countries that do not currently conscript citizens retain the right to do so during wartime. Conscription is an example of coercive state intervention which, even if not widely endorsed, rarely generates outrage or even attention from ethicists.2 For those who accept that coercive conscription could in principle be justified, it is not easy to show why coercive pronatalism must be rejected without argument. Indeed, many of those who are alarmed about declining birth rates …

Mitochondrial replacement therapy has been developed in order to prevent the transmission of mitochondrial mutations, yet it raises ethical concerns, particularly regarding the involvement of third-party DNA and the risks associated with donor procedures. This paper explores an alternative approach using synthetic DNA (synDNA) to construct mitochondrial organelles, thereby bypassing the need for donor oocytes and bypassing risks to donors. We argue that those who support mitochondrial replacement techniques as an ethically acceptable means of preventing the transmission of mitochondrial disease should consider the use of synthetic mitochondria as a preferable ethical alternative, should it prove technically viable. That this will be viable is more than we can demonstrate here. However, progress in synDNA technology suggests that it is not unreasonable to think that synthetic mitochondria creation is feasible, and perhaps even probable.

In recent decades, ethicists have engaged with new developments in human reproductive technologies from a variety of angles. Yet there has been relatively little effort to problematize the concept of reproduction itself. In this paper, we examine the question of what reproduction is and its relationship with biology. We show that reproduction is commonly assumed to entail biological parenthood—an assumption that we term “the biological reproduction paradigm.” Drawing on Sally Haslanger’s analysis of the biological/social division between sex and gender, we suggest that the concept of reproduction is socially constructed, despite its apparently biological nature. In turn, we argue that the supposed necessity of the relationship between reproduction and biological parenthood leads to a situation in which access to a variety of medical, legal, and social goods is constrained on the basis of spurious, inconsistent, and undertheorized assumptions. Finally, we note that, given the socially constructed nature of reproduction, we cannot take it for granted that the term “reproduction” signifies the same thing among different interlocutors and in different contexts.

In this paper, I will explore ideas advanced by Bradshaw, Pence and others who have written on compassion in healthcare. I will attempt to see how and whether their assumptions about compassion can be justified, and explore the role compassion should play in a modern healthcare system. I will justify scepticism at the idea of attempting to incentivise compassion through metrics. The Francis Report raises important questions concerning the nature of a healthcare system that harms rather than helps patients. If something is failing in modern healthcare, those in charge should naturally seek to remedy it. I will investigate whether this is due to the disappearance of compassion, and if so, what is it that is emerging to fill its place. I will consider whether we need to rehabilitate or enforce compassion in the system, or to acknowledge that our modern healthcare systems are incompatible with compassion and how we can make the best of what remains.

In this paper, we identify some key features of what makes something a disease, and consider whether these apply to pregnancy. We argue that there are some compelling grounds for regarding pregnancy as a disease. Like a disease, pregnancy affects the health of the pregnant person, causing a range of symptoms from discomfort to death. Like a disease, pregnancy can be treated medically. Like a disease, pregnancy is caused by a pathogen, an external organism invading the host’s body. Like a disease, the risk of getting pregnant can be reduced by using prophylactic measures. We address the question of whether the ‘normality’ of pregnancy, its current necessity for human survival, or the value often attached to it are reasons to reject the view that pregnancy is a disease. We point out that applying theories of disease to the case of pregnancy, can in many cases illuminate inconsistencies and problems within these theories. Finally, we show that it is difficult to find one theory of disease that captures all paradigm cases of diseases, while convincingly excluding pregnancy. We conclude that there are both normative and pragmatic reasons to consider pregnancy a disease.

In this paper, we discuss the ethical concerns that may arise from the synthesis of human DNA. To date, only small stretches of DNA have been constructed, but the prospect of generating human genomes is becoming feasible. At the same time, the significance of genes for identity, health and reproduction is coming under increased scrutiny. We examine the implications of DNA synthesis and its impact on debates over the relationship with our DNA and the ownership of our genes, its potential to disrupt common understandings of reproduction and privacy, and the way in which synthetic DNA challenges traditional associations between genes and identity. We explore the degree to which synthetic DNA may further undermine overgeneticised accounts of identity, health, reproduction, parenthood and privacy that are prevalent in the public domain and in some areas of policy-making. While avoiding making normative claims of our own, we conclude that there is a need for reflection on the ethical implications of these developing technologies before they are on us.

We recently suggested that there are both pragmatic and normative reasons to classify pregnancy as a disease. Several scholars argued against our claims. In this response, we defend the disease view of pregnancy against their criticism. We claim that the dysfunctional account of disease that some of our critics rely on has some counterintuitive results. Furthermore, we claim that our critics assume what needs to be argued that the primary function of our sexual organs is to reproduce. Since only a small percentage of sexual intercourse leads to pregnancy, it is far from obvious that reproduction is the primary biological function of our sexual organs. We also claim that while taking pregnancy itself as a reference class could avoid the conclusion that pregnancy is a disease, the strategy is problematic since it renders the Boorsean approach to disease and health circular and effectively deprives it of any utility in determining whether a particular phenomenon is a disease or not.

We tend to hold people responsible for their choices, but not for what they can’t control: their nature, genes or biological makeup. This thought-provoking collection redefines the boundaries of moral responsibility. It shows how epigenetics reveals connections between our genetic make-up and our environment. The essays challenge established notions of human nature and the nature/nurture divide and suggest a shift in focus from individual to collective responsibility. Uncovering the links between our genetic makeup, environment and experiences, this is an important contribution to ongoing debates on ethics, genetics and responsibility.

Recent decades have seen the facilitation of unconventional or even extraordinary reproductive endeavours. Sperm has been harvested from dying or deceased men at the request of their wives; reproductive tissue has been surgically removed from children at the request of their parents; deceased adults’ frozen embryos have been claimed by their parents, in order to create grandchildren; wombs have been transplanted from mothers to their daughters. What is needed for requests to be honoured by healthcare staff is that they align with widely shared expectations about what people’s reproductive potential ought to be, what marital relationships ought to result in, and which kinds of ties are desirable between parents and children. Costly and invasive technologies are not considered excessive when they are used to support the building of appropriate families. However, deviations from dominant reproductive norms, even if technologically simple and convenient to the participants, are unlikely to receive support. In this paper, we offer examples of such deviations and explore their implications. If reproduction is important as a way of creating genetic relationships, should reproductive material in storage be offered to genetic relatives other than the people from whom it originated? And if parents are allowed to have reproductive material collected from their offspring, or even to use it to create babies, should offspring likewise be allowed to use their parents’ reproductive material? We tackle these questions and suggest ways in which interests in genetic ties could be operationalised in a more coherent and less-invasive manner than they currently are.

Appiah distinguishes between people who are racist because they are motivated by strong ideological convictions, and those who are racist because they believe certain facts to be true. I explore to what extent this distinction might apply to those who believe in racial equality. I show that it may be risky to ignore race-related factors in the health context, while acknowledging that what constitutes race may be open to question. I discuss the idea that there are no morally relevant differences between races, however construed. I show that to base one's belief in moral equality on empirical claims, is not only inherently problematic, but in most cases, is a false account of what really motivates such beliefs. Instead, I argue that we should embrace the ideological element of a belief in moral equality. Thus, instead of arguing about whether race exists, or whether there are morally relevant differences between races, (however construed), we may open a pathway to a more honest and challenging debate. That is, how can one moral ideology demonstrate its superiority over another?.

When contemplating reproductive choices, we commonly feel that there are some actions that would harm our future offspring. But in cases where a decision may affect not only the characteristics of our children, but their very identity, this intuition founders. Parfit famously terms this the ‘non-identity problem’. Many scholars interpret Parfit as endorsing a genetic account of identity. Such an account seems to imply that identical twins are in fact the same person. Moreover, it suggests that there is no such thing as gene therapy, since a change of genes results in a different person, rather than curing an existing person. An epigenetic understanding of identity enables us to make sense of the fact that twins are not the same person, but this suggests that we are not harmed by, for example, disease caused by epigenetic changes in response to environmental pollution. Instead, we simply become different people. Since identity is such a biologically complex concept, it is not clear that its relationship with harm in the context of reproductive choices offers any easy solutions within the broadly utilitarian framework that Parfit offers.

Louise Brown's birth in 1978 heralded a new era not just in reproductive technology, but in the relationship between science, cells, and society. For the first time, human embryos could be created, selected, studied, manipulated, frozen, altered, or destroyed, outside the human body. But with this possibility came a plethora of ethical questions. Is it acceptable to destroy a human embryo for the purpose of research? Or to create an embryo with the specific purpose of destroying it for research? In an attempt to construct ethical and legal frameworks for the new era of cellular reprogramming, legislators and ethicists have tried to distinguish between different kinds of biological entity. We treat cells differently depending on whether they are human or animal, somatic cells or gametes, and on whether they are embryos or not. But this approach to the ethics of cellular reprogramming is doomed to failure for the simple reason that cellular reprogramming in itself destroys the distinctions that the law requires to function. In this article, we explore the historical trajectory of cellular reprogramming and its relationship with ethics and society. We suggest that the early hype of embryo research has not obviously fulfilled expectations, but since new avenues of research are continuously opening, it is hard to say definitely that these promises have been broken. We explore the forthcoming challenges posed by the creation of DNA from scratch in the laboratory, and the implications of this for understandings of identity, privacy, and reproduction. We conclude that while ethics used to seek answers in biological facts, this is no longer possible, and a new approach is required.

In this paper, we will discuss the prospect of human reproduction achieved with gametes originating from only one person. According to statements by a minority of scientists working on the generation of gametes in vitro, it may become possible to create eggs from men’s non-reproductive cells and sperm from women’s. This would enable, at least in principle, the creation of an embryo from cells obtained from only one individual: ‘solo reproduction’. We will consider what might motivate people to reproduce in this way, and the implications that solo reproduction might have for ethics and policy. We suggest that such an innovation is unlikely to revolutionise reproduction and parenting. Indeed, in some respects it is less revolutionary than in vitro fertilisation as a whole. Furthermore, we show that solo reproduction with in vitro created gametes is not necessarily any more ethically problematic than gamete donation—and probably less so. Where appropriate, we draw parallels with the debate surrounding reproductive cloning. We note that solo reproduction may serve to perpetuate reductive geneticised accounts of reproduction, and that this may indeed be ethically questionable. However, in this it is not unique among other technologies of assisted reproduction, many of which focus on genetic transmission. It is for this reason that a ban on solo reproduction might be inconsistent with continuing to permit other kinds of reproduction that also bear the potential to strengthen attachment to a geneticised account of reproduction. Our claim is that there are at least as good reasons to pursue research towards enabling solo reproduction, and eventually to introduce solo reproduction as an option for fertility treatment, as there are to do so for other infertility related purposes.

The family is commonly regarded as being an important social institution. In several policy areas, evidence can be found that the family is treated as an entity towards which others can have moral obligations; it has needs and interests that require protection; it can be ill and receive treatment. The interests attributed to the family are not reducible to those of its members – and may even come into conflict with them. Using Warren's criteria for moral status, we show that, although the status of the family is not explicitly described in terms of moral status, the way in which it is treated implies that it has such status.

In this paper we look at the implications of an emerging technology for the case in favor of, or against, postmenopausal motherhood. Technologies such as in vitro derived gametes have the potential to influence the ways in which reproductive medicine is practiced, and are already bringing new dimensions to debates in this area. We explain what in vitro derived gametes are and how their development may impact on the case of postmenopausal motherhood. We briefly review some of the concerns that postmenopausal motherhood has raised—and the implications that the successful development, and use in reproduction, of artificial gametes might have for such concerns. The concerns addressed include arguments from nature, risks and efficacy, reduced energy of the mother, and maternal life expectancy. We also consider whether the use of in vitro derived gametes to facilitate postmenopausal motherhood would contribute to reinforcing a narrow, geneticized account of reproduction and a pro-reproductive culture that encourages women to produce genetically related offspring at all costs.

Who is a child’s father? Is it the man who raised her, or the one whose genes she carries—or both? We look at the view that men who have raised children they falsely believed to be ‘their own’ have been victims of a form of fraud or are ‘false fathers’. We consider the question of who has been harmed in such cases, and in what the harm consists. We use conceptual analysis, a philosophical method of investigating the use of a concept and the logical implications of its various interpretations. We devise and discuss a number of possible scenarios in which a couple (arguably) become the parents of a child. We use these scenarios to illustrate the tenuousness of the claim that we can simply rely on biology to clarify parent-child relationships. We also discuss some of the underpinnings and implications of the language in which the debate on ‘paternity fraud’ has been framed: ‘duped’ or ‘false’ fathers and ‘cuckoo children’.

My paper on assent and reification in research involving adults with impairments of capacity and/or communication (AWIC)1 drew many thoughtful and insightful responses. I am grateful to all who submitted commentaries. Most agreed in principle that AWIC could be better represented in medical research. However, several commentators felt that further clarification was needed in terms of what assent is and how it should be obtained and operationalised.2 I fully agree that if increased representation of AWIC is to come about through an assent-based approach, further clarificatory work is needed, and am glad to think my paper may function as a stimulus for this. Some commentators worry that an assent-based approach will impose heavy demands on researchers and entail higher costs.2 I acknowledge this, but would argue that if better inclusion of AWIC is a worthwhile goal, we should be willing to accept some costs. The move from an exclusionary to an inclusive approach will become less demanding once it is accepted as the default. And as I argue in my paper, we have resources on which to draw, including materials designed to facilitate comprehension and communication with AWIC that have been developed in other spheres,3 as well as existing protocols and structures that facilitate …

In this paper we will look at the various ways in which infertility can be understood and at how need for reproductive therapies can be construed. We will do this against the background of research with artificial gametes. Having explored these questions we will attempt to establish the degree to which technologies such as AGs could expand the array of choices that people have to reproduce and/or become parents. Finally, we will examine whether and in what ways the most promising developments of such technologies are likely to bring about the “end of infertility”

In debates on the ethics of artificial gametes, concepts of naturalness have been used in a number of different ways. Some have argued that the unnaturalness of artificial gametes means that it is unacceptable to use them in fertility treatments. Others have suggested that artificial gametes are no less natural than many other tissues or processes in common medical use. We suggest that establishing the naturalness or unnaturalness of artificial gametes is unlikely to provide easy answers as to the acceptability of using them in fertility medicine. However, we also suggest that we should be cautious about repudiating any relationship between nature and moral evaluation. The property of being natural or man-made may not per se tell us anything about an entity’s moral status, but it has an important impact on the moral relationship between the creator and the created organism.

In applied ethics, and in medical treatment and research, the question of how we should treat others is a central problem. In this paper, I address the ethical role of assent in research involving human beings who lack capacity. I start by thinking about why consent is ethically important, and consider what happens when consent is not possible. Drawing on the work of the German philosopher Honneth, I discuss the concept of reification—a phenomenon that manifests itself when we fail to observe or respond to our fellow humans’ need for recognition. I suggest that assent is a way of responding to this moral need for recognition, which exists independently of cognitive capacity. I will look at the circumstances in which consent cannot be obtained from human beings, and ask whether some of the same ethically important considerations that underpin the need for consent might be achieved through seeking assent. I discuss the ways in which this might be beneficial for researchers, for prospective research participants and for society at large.

Whole body gestational donation offers an alternative means of gestation for prospective parents who wish to have children but cannot, or prefer not to, gestate. It seems plausible that some people would be prepared to consider donating their whole bodies for gestational purposes just as some people donate parts of their bodies for organ donation. We already know that pregnancies can be successfully carried to term in brain-dead women. There is no obvious medical reason why initiating such pregnancies would not be possible. In this paper, I explore the ethics of whole-body gestational donation. I consider a number of potential counter-arguments, including the fact that such donations are not life-saving and that they may reify the female reproductive body. I suggest if we are happy to accept organ donation in general, the issues raised by whole-body gestational donation are differences of degree rather than substantive new concerns. In addition, I identify some intriguing possibilities, including the use of male bodies–perhaps thereby circumventing some potential feminist objections.