P-268 Surrogate mothers: background and motivations

Abstract

Study question

It's a preliminary report to clarify motivations of intended surrogate mothers and “experienced” surrogates and, taking into consideration their background, specify if their main motive is an altruistic wish to help childless people to become parents, either it's all about money, or the surrogates are driven by combination of different motives.

Summary answer

There is no main driving force behind surrogacy and, although financial remuneration is essential for many surrogates, it's almost always a mix of several motivations, including a sincere wish to help and a need to improve their own living conditions.

What is known already

Beyond money surrogates might have very different motives, such as guilt over a past abortion, or just like to be pregnant.

Study design, size, duration

The study has been conducted for 6 months from August 2012 to January 2013. Only gestational surrogacy was studied as traditional surrogacy, when own oocytes of a surrogate are used, is out of law in Russia.

Participants/materials, setting, methods

100 e-mail questionnaires were sent out to women who applied to European Surrogacy Center in Moscow to become gestational surrogates in 2012. 73 participants, among them 9 experienced surrogates, 28 first time surrogates incl. 7 who became pregnant in 2012, completed the 30 question form by e-mail.

Main results and the role of chance

The mean age of the entire group was 29. 54% were married, 15% divorced, 12% had a partner. All participants had children (63% - 1, 22% - 2, 15% - 3). 29% graduated from a higher school, 3% were students, 68% graduated from a college. Only 36% were employed, 64% were housewives, supported by husbands (56%). 68% owned an apartment, 25% rented it, 7% owned a house. No participant lived in poverty or needed any support to survive.

Main motivations for becoming a surrogate, almost always combined: to help – 74%, to improve living conditions – 43%, to improve financial situation – 16%, for studies or treatment of their children – 15%, to return a credit – 14%, liked to be pregnant – 12%, remorse for an abortion – 7%, to buy a car – 5%, to start own business – 4%.

44% declared that they would bear a child to their relative or close friend free of charge. 15% would agree to help to anyone in need for free. 4% expressed that their only motive was to help, although 26% declared no wish to help at all, being money their most important motivation.

Limitations, reason for caution

Commercialization of child bearing and its implications should be thoroughly studied. Further studies of surrogates, their motivations and psychology should be conducted in countries were surrogacy is allowed.

Wider implications of the findings

There would be no surrogate industry and no children born without substantial financial remuneration paid to surrogates. An altruistic surrogacy is confined to a small circle of relatives and close friends and cannot help all who might need it. Legalization of altruistic surrogacy won't help those who need urgent help. Commercial surrogacy should be allowed on a wider level to enable childless people to become parents.

Study funding/competing interest(s)

I declare no competing interests.

Trial registration number

There is no trial registration number.

P-269 What constitutes parenthood according to both genetically and non-genetically related mothers (lesbian parents)

Abstract

Study question

What constitutes parenthood according to partners in lesbian couples with children? How do they define parenthood and what criteria do they consider relevant in the attribution of parental rights in a hypothetical scenario?

Summary answer

The criteria described in the literature (genetic/gestational link, social bond, intention and causation) were present as monistic or necessity accounts in how these mothers dealt with the scenario. When applying these accounts of parenthood to their own situation, this often profoundly challenged either their own or their partner's status.

What is known already

The existence of families with genetically and non-genetically related parents has given rise to questions about the definition of parenthood. Views about what constitutes parenthood and which parental rights can be attributed to whom depend on the particular moral theory of how one becomes a parent. The criteria used to determine parenthood (such as intention) as well as their theoretical foundations are discussed in the literature. This study focusses on the views of stakeholders.

Study design, size, duration

Semi-structured interviews were conducted between October and December 2012 with lesbian parents who were successfully treated with DI (with sperm from anonymous donors) between 2002-2005 at the Department of Reproductive Medicine of the Ghent University Hospital. Step-by-step inductive thematic analysis resulted in themes that were compared with the literature.

Participants/materials, setting, methods

20 partners of 10 couples were included. This paper presents the analysis of responses to a hypothetical scenario of a gamete mix-up in a lab that resulted in three types of ‘parents’ who each separately claimed parental rights: genetic and social parent (GSP), genetic parent (GP) and social parent (SP).

Main results and the role of chance

Participants were asked to choose between four types of rights (ranging from full custody to no contact) for each ‘parent’ and elaborate on their decision. Most mothers automatically granted maximum rights to GSP whereas choosing rights for parents with only one of the two ties was considered much more difficult. At this stage, there were substantial differences between participants (irrespective of their own genetic parenthood status) in the weight attributed to the genetic and the social link. Also, intention and causation were identified as key criteria to be granted parenthood. Some participants granted no rights to SP based on the absence of a genetic link. These mothers described a view that, when compared to their own situation, disqualified either themselves or their partners as parents.

Limitations, reason for caution

The use of hypothetical scenarios facilitates data collection on moral reasoning. However, caution is needed when making assumptions about how participants would (re)act in the social reality. Interviewing partners together has probably influenced their responses but also adds an extra dynamic to the interview because they probed each other's responses.

Wider implications of the findings

The scenario facilitated an in-depth discussion of an important question in the field of reproductive medicine and provided us with unique data from a group that is usually only the subject of the discussion. Findings of this empirical bioethics study can stimulate the debate in the literature. They can provide valuable insights into stakeholders’ reflections that can contribute to the development of moral theories about social and genetic parenthood and the attribution of parental rights.

Study funding/competing interest(s)

The project is funded by the Special Research Fund of Ghent University. Approval by the appropriate Ethics Committee has been obtained.

Trial registration number

None

P-270 Revisiting the fourteen-day limit for human embryo-research

Abstract

Study question

As new developments may enable human embryo-research to move toward and beyond the internationally accepted ‘fourteen-day limit’, the question whether this limit should be upheld against promising research seems no longer fully hypothetical. What are the ethical arguments behind the fourteen-day limit and how convincing are they?

Summary answer

The existing consensus reflects the will of policy-makers to draw a line somewhere rather than a shared understanding of why precisely this should be at fourteen days and not at some other developmental stage. None of the reasons given for a limit at fourteen days are argumentatively convincing.

What is known already

The reason why until now there has been no debate about the fourteen day limit is that it was not possible to culture human embryos for longer than around a week. This may change now that British researchers (Cambridge) have developed a culture system that allows studying mouse embryonic development in stages that normally occur after implantation. The findings have led to interest in studying ‘post-implantation’ human embryonic development through extended in-vitro culture.

Study design, size, duration

In this explorative study, we have charted the ethical arguments behind the fourteen day limit as presented in the philosophical literature about human embryo research and in relevant (inter)national policy and legal documents. We have determined the convincingness of these argument in terms of their internal and external consistency.

Participants/materials, setting, methods

The study consists of a review of the arguments in the ethics literature followed by a theoretical reflection and conclusion. The method is that of ‘wide reflective equilibrium’, aimed at finding a balance between moral intuitions, background theories and ethical reflection.

Main results and the role of chance

Extended human embryo research may lead to important knowledge about early post-implantation development (both in terms of basic science and health care applications) that cannot otherwise be obtained. However, it would violate the widely accepted fourteen day limit, raising the question whether that should be a reason to refrain from such research. An often proposed argument for this limit is that of ‘ontological individuality’, holding that the moment after which embryonic division is no longer possible should be regarded as an ethically relevant transition point. Still, the question remains whether this and other arguments provide sufficient backing for a limit at fourteen days. Those contesting this have pointed at other transition points that would be ethically more important, such as the beginning of brain-activity.

Limitations, reason for caution

This is an explorative study that does not answer the question under what conditions extended human embryo research would be ethically acceptable if the fourteen-day limit is regarded as too restrictive, or at what stage an alternative limit should be drawn.

Wider implications of the findings

Our conclusions make clear that an accepted element of the normative framework for human embryo research may be less firmly rooted than many would have thought. Instead of uncritically using the accepted limit to curb scientific developments, policy makers should accept that there may be sound ethical reasons for fine tuning the balance between embryo protection and reaping the benefits of embryo research. This fine tuning will require further ethical reflection and societal debate.

Study funding/competing interest(s)

Both authors: Dept of Health, Ethics & Society, and GROW research school, Maastricht University, the Netherlands. The authors declare no competing interest.

Trial registration number

N/A

P-271 iPS cell derived gametes for reproduction ñ why not?

Abstract

Abstract withdrawn by the author

P-272 Comprehensive embryo screening and selection in preimplantation genetic diagnosis (PGD) and preimplantation genetic screening (PGS) and the right of the child to an open future

Abstract

Study question

One of the objections to comprehensive embryo screening (CES) uses Feinberg's concept 'the right of the child to an open future' (ROF). Is this argument applicable to this context and is it a valid reason to disallow comprehensive screening of embryos?

Summary answer

The transfer of comprehensively sequenced embryos seems to violate recommendations regarding the genetic testing of minors and a child's ROF, as it also reveals information that is not directly actionable. However, considerations regarding the benefits to harm ratio suggest that, under further conditions, CES may still be warranted.

What is known already

High resolution genetic screening technologies such as microarrays are being introduced in PGD and PGS to assist embryo selection. Embryos could be screened either for a subset of severe genetic disorders to deselect affected embryos or comprehensively screened to set up health profiles, which allow selection of the best embryo. In the ethics literature on genetic testing of minors, Feinberg's ROF-argument is used against comprehensive screening of minors.

Study design, size, duration

We have investigated the philosophical arguments behind the claim that ROF limits the extent to which genetic testing of minors should be allowed, and checked to which extent these arguments can be transferred to the context of the in vitro embryo.

Participants/materials, setting, methods

The study consists of a review of the arguments in the ethics literature followed by a theoretical reflection and conclusion. The method is that of 'wide reflective equilibrium', aimed at finding a balance between moral intuitions, background theories and ethical reflection.

Main results and the role of chance

Given the limited amount of embryos available after IVF, and the probability that no embryo will be mutation-free, CES implies transfer of embryos with known mutations. This seems at odds with guidelines limiting genetic testing of minors. A strict interpretation of the deontological argument behind these guidelines (respect for future autonomy) leaves little room for CES. We advocate a consequentialist (or mixed) approach promoting a balance between potential harms and benefits. This would leave only a subset of possible findings that would make transfer morally unacceptable in the light of ROF, for example serious non-treatable late-onset disorders, but possibly also certain susceptibilities knowledge of which might adversely affect parent-child interaction. Our approach allows CES if conditional upon non-transfer of findings in these categories.

Limitations, reason for caution

Our conclusion seems to violate certain recommendations and regulations regarding the genetic testing of minors. As this is an explorative study, further research, also involving stakeholder views (including professionals, patients, parents and children), will be necessary.

Wider implications of the findings

A rethinking of Feinberg's ROF in terms of a balance between benefits and harms allows for a wider number of conditions and mutations to be screened for in the context of PGD and PGS and for an ethical transition of the existing paradigm of not transferring an affected embryo to transferring the embryo with the best chance of good health. Still, a reflection is needed on what knowledge can actually harm potential future children.

Study funding/competing interest(s)

All authors: GROW research school, Maastricht University. K. Hens is funded by the Dutch Centre for Society & the Life Sciences. The authors declare no competing interest

Trial registration number

N/A

P-273 Cross-border reproductive care in Europe and medical liability litigations: which court is competent and which law is applicable

Abstract

Study question

In the past decade, there has been a steady rise in cross-border reproductive care (CBRC) within Europe. However, the legal position of fertility centers is insecure when foreign patients complain they are unduly treated. Which national court is entitled to handle such cases and which law is applicable?

Summary answer

Several member state courts can be entitled to decide on CBRC liability litigations according to various possible law systems. In accordance with the EU Guideline 2011/24 the development of compulsory CBRC safety standards is therefore strongly recommended. Meanwhile, drawing up contractual agreements is advised to avoid legal insecurity.

What is known already

The European Union has enacted complex directives on cross-border litigations. Some determine the competent court (e.g. Directive 44/2001), other the applicable law (e.g. Directive 593/2008). According to Guideline 2011/24 cross-border healthcare should be offered according to the regulations of the member state in which the treatment is carried out, as well as the “union legislation on safety standards”. Except for the Tissue Directive 2004/23, no uniform European standards on reproductive care have been enacted yet.

Study design, size, duration

This study analyses the competent court and applicable law if a fertility center established in member state ‘X’ is accused of medical malpractice by a patient living in member state ‘Y’. Examples of possible malpractices are the excessive hormonal stimulation and inadequate follow-up of PCOS patients causing ovarian hyperstimulation syndrome and transferring a high number of embryos causing intrauterine growth retardation and preterm delivery or heterotopic pregnancies[1].

[1] Mancini F, Clua E, Martinez F, Battaglia C, Veiga A, Barri P. Heterotopic pregnancy in a cross border oocyte donation patient: the importance of cooperation between centers. Fertil Steril2001; 95(7): 2432.e13-5 (in this case one of the two transferred donor embryos caused a heterotopic pregnancy).

Participants/materials, setting, methods

For such cases the legal consequences of the EU regulations were studied. Therefore a thorough research of the official EU texts, interpretations by the European jurisdiction and the legal doctrine was conducted.

Main results and the role of chance

Except for criminal offenses, fertility centers can freely stipulate the competent court and applicable law in patient contracts or consent forms. In the absence of such clauses, patients can bring their center to the court of the state in which it is established or in which the treatment is carried out (usually the same). If the consumer protection regulations apply to CBRC (which is unclear) centers can also be sued in the patient's country of origin.

If the applicable law was not determined in advance, the center's liability is assessed according to the regulations of the state in which it is established. So long as no compulsory European reproductive guidelines are enacted (e.g. on embryo transfer) centers are only bound by national due care criteria.

Limitations, reason for caution

The EU regulations on CBRC litigations are complex, often unclear and sometimes contradictory. If patients are protected as consumers, the centers’ contractual freedom is limited. Legal insecurity also arises if medical contracts are manifestly more closely connected with another country, e.g. if domestic gynecologists and foreign fertility centers collaborate intensively.

Wider implications of the findings

To reduce legal discussions, the EU should clarify which regulations specifically apply to CBRC cases. Meanwhile, fertility centers are recommended to stipulate in the consent forms that patient complaints can only be assessed by the courts and laws of the state in which they are established. Nevertheless, the development of binding European safety standards for reproductive care is essential to avoid different interpretations by the national courts. ESHRE's role in this evolution can be crucial.

Study funding/competing interest(s)

Ghent University - no competing interests

Trial registration number

none