Reimagining autonomy in reproductive medicine
Do the reproductive choices of prospective parents truly align with their values and priorities? How do doctors, reproductive technologies, and the law influence those choices? And why should certain women receive medical assistance to establish a pregnancy, while others are put in jail when they miscarry? A new Hastings Center special report, Just Reproduction: Reimagining Autonomy in Reproductive Medicine, considers these and related questions. It is a supplement to the Hastings Center Report, November-December 2017.
The report originated from presentations given at the Center for Bioethics at Harvard Medical School's 2017 conference entitled "The Ethics of 'Making Babies.'" Editors of the report are Louse P. King, assistant professor of obstetrics, gynecology, and reproductive biology at Harvard Medical School and the director of reproductive bioethics at its Center for Bioethics; Rachel L. Zacharias, project manager and research assistant at The Hastings Center; and Josephine Johnston, The Hastings Center's director of research.
"In today's dialogue about reproduction, medicine, and ethics in the United States, old ethical issues—such as whether women ought to be allowed to access pregnancy termination—are more contested than they have been in decades, while new technologies—like those used to edit the genes of human embryos—suggest that our species could face unprecedented questions about who should exist," states the introduction. In addition, there are socioeconomic and geographic disparities in access to assisted reproduction technologies, as well as in the enforcement of laws that affect reproduction.
Questions addressed in the report include the following:
What financial and other constraints limit an individual's reproductive choices?
The choices of many U.S. fertility patients about which kinds of fertility treatments to use and how aggressively to use them may be heavily constrained by financial concerns, write Johnston and Zacharias in "The Future of Reproductive Autonomy." And while women may freely consent to prenatal screenings, some may feel that consent is what their clinicians expect of them. In the face of financial, clinical, familial, cultural, and other pressures, when can one say that an individual's reproductive choices are truly autonomous? This essay proposes that attaining a "reproductive autonomy worth having" means identifying constraining pressures in making reproductive decisions and fostering conditions for people to act in true accordance with their values and priorities. Johnston is the principal investigator on The Hastings Center's current project Goals and Practices for Next-Generation Prenatal Testing.
How does the "criminalization of pregnancy" cause racial disparities in reproductive autonomy?
In 2003, the South Carolina Supreme Court upheld the conviction of Regina McKnight, an African American woman who was convicted at the age of twenty-two for committing "homicide by child abuse." She became the first woman in the U.S. to be arrested, prosecuted, and convicted for experiencing a stillbirth. "How the Criminalization of Pregnancy Robs Women of Reproductive Autonomy" explores how laws previously understood to protect pregnant women from domestic violence, such as fetal protection laws, now serve as the vehicles for prosecuting pregnant women, particularly disadvantaged women of color. The author, Michele Goodwin, a chancellor's professor at the University of California, Irvine, examines the differential treatment of poor women of color, who may be criminalized during their pregnancies, and advantaged white women, who may place their pregnancies at risk via their use of reproductive technologies but are not subject to similar policing.
Should doctors ever limit their patients' requests for fertility treatments?
In reproductive medicine, patients may select from an ever-widening array of options, including ones they've found online. In an effort not to impinge on a woman's or a family's exercise of individual autonomy, physicians in reproductive medicine might feel compelled to comply with decisions they find ill-advised. These might include requests to select the sex of an embryo for nonmedical purposes or to transfer multiple embryos, despite the increased risks. In "Should Clinicians Set Limits on Reproductive Autonomy?," Louise P. King, a gynecologic surgeon with a focus on infertility, explores the extent to which clinicians in reproductive medicine should follow patient requests that they disagree with or instead try to persuade the patient to choose a different option.