7
THE MEDICO-LEGAL SOCIETY A meeting ofthe Medico-Legal Society was held on Thursday 9 February 1989. The President, DrJ.D.K. Burton, was in the Chair.
ASSISTED CONCEPTION by Professor IAN CRAFT, FRCS, FRCOG, Head of the Fertility & IVF Unit, Humana Hospital Wellington, London, NW8 9LE THE DEVELOPMENT ofadvances in fertility, particularly those occurring in the last decade as the result of assisted conception treatment, has brought with it a plethora of public anxieties. Assisted conception, i.e. that occurring other than by natural intercourse following medical treatment, now embraces methods which have been designated with an ever-increasing number of acronyms, e.g. AI, DIPI, lUI, IVF/ET, GIFT, 21FT, etc. In essence, the basic concept behind each has been an attempt to ensure that a sample of semen is appropriately processed so that sperm are potentially capable offertilising eggs (oocytes) at a time when the latter are about to be released from the ovary. This may occur either naturally following release of nature's own stimulus (luteinising hormone - LH) or following a surrogate stimulus achieved by the administration ofhuman chorionic gonadotrophin (HCG). Oocyte development may either occur naturally, usually with the release ofa single oocyte, or following drug induction, using agents to promote the developments ofmultiple oocytes. This may be achieved either by administering injections ofgonadotrophins which raise the threshold of stimulation or by administering tablets, e.g. clomiphene citrate, which result in the pituitary gland secreting more endogenous gonadotrophins. These agents are frequently used in combination. Different women exhibit varying potentials of response to such agents, some making cohorts of few oocytes and others making cohorts of many. The oocytes produced are usually of varying grades of maturity and have differing potentials for both fertilisation and the development of embryos which themselves have different abilities to implant. The assisted conception methods most commonly used include artificial insemination (AI), now most usually performed using washed sperm injected directly into the uterine cavity, i.e. intrauterine insemination (lUI). In-vitro fertilisation and embryo transfer (IVF/ET) consists of fertilising oocytes, recovered either by laparoscopy or by ultrasound methods, in a defined culture medium in an incubator at 37°C with prepared sperm, and subsequent transfer of some, or all, of the resultant embryos into the uterus via the cervical canal some 24-48 hours later. Gamete intrafallopian transfer (GIFT) consists of transferring oocytes and sperm into one or both open fallopian tubes by laparoscopy at the actual time ofoocyte recovery so that fertilisation occurs in-vivo, as opposed to in-vitro, with IVF. Why then has assisted conception technology become the subject of such emotive feeling in the community since the first test-tube baby was born in 1978? In my view this has in part been due to the public becoming aware of differences of opinion
8
Medico-LegaLJouma158/1
between doctors and scientists, some of whom have used the media to be critical of their colleagues' points of view, rather than direct such comments to the editorial columns ofthe BMJ or Lancet. It would certainly be preferable ifmore attention was given to using the media to provide basic science information for the public on the subject ofearly human development, and on the causes and treatment of infertility. Had this been the case there might have been fewer concerns, and more informed opinion, about the anxieties outlined in Table 1. Table 1
Anxieties Concerning Assisted Conception 1. 2. 3. 4. 5. 6. 7.
Research on human embryos* The use of donated oocytes, sperm, embryos The cryopreservation of oocytes, sperm, embryos The use of known/anonymous donors* The risk and sequelae of multiple pregnancy* Selective reduction of pregnancy* Surrogacy
Those marked with an asterisk have provoked the greatest reaction especially as the surrogacy issue has received less attention following implementation of the Surrogacy Arrangements Act, 1985. The reaction to these different issues depends on whether one is infertile, a member of the medical and scientific community, or an uninvolved member of the general public. In most instances people are either generally for or against an issue as they perceive it, even allowing for the fact that they frequently do not fully understand the biological realities of human life which have relevance to the issue concerned. To many people (including lawyers) a human embryo is considered synonymously with an unborn child and yet a human conceptus consisting ofa mass ofcells cannot even start to differentiate to a formative embryo and placenta until after successful implantation has occurred, i.e. many days after fertilisation. Many human embryos generated both naturally and after fertility treatment exhibit chromosome and other structural abnormalties which preclude normal development and therefore could not possibly lead to a child being born. Therefore many anxieties and views are based upon total misconceptions about the realities oflife itself and are probably influenced by one's upbringing, religious view, etc. These considerations do not preclude the concept that there should be respect for human embryos and their potential for life. In order to try to assess the main anxieties of infertile patients and their referring doctors - both GPs and specialists, Miss Elly Fincham from our Department conducted a questionnaire/survey ofthese two groups and evaluated the responses from approximately 1,000 infertile couples and 200 doctors.
Research on human embryos Table 2 shows that ofthe four major concerns, infertile couples were most worried about research being performed on human embryos, whilst this was the second major
9
Assisted Conception
concern of doctors. Of the latter, 64% considered embryos should be made specifically available for research after fertilisation ofdonated oocytes from normal fertile volunteers, and yet 19 % thought the research should be performed on embryos left over from a given couple's treatment cycle, even though they may have been available for that couple's future benefit. Table 2
Major anxieties of assisted conception Research on human embryos ii. Anonymity of donor gametes iii. Risk and sequelae of multiple pregnancy iv. Selective reduction of pregnancy
1.
Doctors 33 %
Patients 69 %
8% 45 % 8%
1% 17 % 5%
Only 5 % ofinfertile couples wanted their excess embroyos to be used for research and 70 % wished them to be frozen for their potential future use. However, 20 % were happy to consider that their excess embryos might be available for the benefit of another infertile couple. In the event ofmarital break-up or death, 64 % wanted their embryos to be donated to other infertile couples and only 10% wanted them to be used for research or to be thawed without use. The fact that so few couples wish to have their embryos used for research, when offered other realistic alternatives such as cryopreservation, questions whether it is morally correct to undertake research on human embryos of infertile couples. Some fertility units do not have active freezing programmes for resultant excess embryos so the choice of disposal is limited. The recent government White paper (items 50,51) indicated that the "storage authority" should not have the right ofuse, or disposal, ofoocytes/embryos unless specifically granted this by the donor - a view which I support. However, the question as to who owns oocytes, sperm, and embryos remains unanswered in legal terms. Indeed, women appear to have no legal rights over the use and disposal oftheir own oocytes/embryos, even though they have the right to affect their reproductive function in other ways, e. g. by hysterectomy, sterilisation and therapeutic abortion.
Oocyte donation Table 3 indicates the response of infertile couples and doctors to a question concerning the anonymity of donors. Very few thought that the donor should always be known. There was a greater suport for having a flexible policy to suit individual circumstances from patients than their referring doctors.. The view expressed by the Interim Licensing Authority (ILA) is that known donors should not be used on the assumption that this may be associated with a high incidence of subsequent emotional and other problems for offspring resulting from such treatment. However, it is my view that known donors should be available in certain situations after appropriate counselling and screening. It seems extremely unfair and illogical for society to insist that a sister may not receive the oocytes ofher own biological sister, thereby ensuring she has her own genetic background. In some cultures it is the practice for some
10
Medico-Legal Joumal 58/1
infertile couples to receive children from their fertile relatives to circumvent childlessness. This practice is rarely associated with adverse sequelae and it would bean unfortunate situation if the proposed Statutory Licensing Authority (SLA) make the recommendation that donors should always beanonymous into an inflexible and definitive rule. Table 3
Anonymity of donors i. The donor should always be anonymous ii. The donor should always be known iii. Donors may be known or anonymous to suit different circumstances
Doctors 52% 3%
Patients 25% 2%
38%
69%
The government White paper (item 80) indicated that where a child results from treatment using donated gametes or embryos, the carrying mother shall be regarded in law as the child's mother, which I support. However, the medical profession and patients alike have anxieties about another recommendation (item 84) that it may be possiblefor children born following gamete donation to be granted access to identifying information which may become retroactive.
Selective reduction of pregnancy This subject, although not considered a major concern by infertile couples and doctors, has preoccupied the ILA and because of their concern the media have given it an undue amount of attention. Even so, 55 % of doctors interviewed thought this practice should beallowed for specific medical indications and 31 % thought it should be available at a given patient's request. Only 9% of doctors thought it should be prohibited. The reason why it has come into prominence at all stems from the fact that, although it has been performed in the U.K. for a decade or more for the elimination of fetal abnormality, usually in the mid-trimester, it is now possible to reduce a multiple pregnancy to a lower order in the first trimester because of developments in imaging techniques. Another reason for its notoriety is based upon uncertainties as to its position in law, even allowing for the fact that it has been performed as a routine service at King's College Hospital in London for many years without the specialists invoking the Abortion Act until recently. Doctors have acted in good faith and the Royal College of Obstetricians and Gynaecologists (RCOG) and the Department of Health (DHSS) must have been aware of its use without proferring advice on the medico-legal uncertainties. The Life Organisation has taken advantage of the uncertain medico-legal position by making a request that the DPP investigate individual doctors in the hope that a prosecution would result in a successful conviction and thereby indirectly lead to a change in the 1967 Abortion Act. Some of the differences between the view ofclinicians and lawyers on this subject have been based upon the understanding, or misunderstanding, of semantics. Doctors
AssistedConception
11
consider that a woman is pregnant if she exhibits features of pregnancy and this condition is not necessarily synonymous with her' 'being with child" . Consequently, to many doctors it is not possible for a woman to be multiply pregnant; she either exhibits the features ofpregnancy or not. Similarly, a lawyer may consider selective reduction of pregnancy may result in a partial miscarriage which is a condition unrecognised by clinical doctors. Miscarriage is either complete or incomplete, and the latteris frequently associated with sepsis, if unattended to. Therefore, in general parlance it is not possible to have a partical miscarriage. Legal opinions obtained by the DHHS, RCOG and individual fertility specialists on this subject have provided differing advice. While most have indicated that the Abortion Act covers this technique, the QC's opinion obtained on behalf of my medical defence society (Medical Protection Society) indicated that: i)
Selective reduction of pregnancy may be an Offence against the Persons Act, 1861 ii) The Abortion Act, 1967, may not be capable of affording protection and iii) There may be a possible risk under the Infant Life (Preservation) Act 1929.
It would be most unfortunate if a doctor was prosecuted in order to clarify a medicolegal uncertainty, especially when the practice of selective reduction ofpregnancy has been used, albeit rarely, for defined medical indications for so long now, with responsible authorities being in full knowledge of that fact.
Surrogacy The Surrogacy Arrangements Act, 1985, was enacted soon after the birth of baby Cotton which evoked emotive media coverage and hasty legislation. The Act has led to a number ofuncertainties and as a consequence, doctors and lawyers are both under potential threat of prosecution if they accept a fee for giving professional advice to prospective clients, irrespective ofthe fact that they are not in essence involved with making any surrogate arrangement. This situation is to be regretted since there was no need for such hasty action. More informed debate and discussion could have resulted in better legislation. Although the number of infertile couples requiring surrogacy is extremely small, their medical problems nevertheless remain profound. Surrogacy need not be the worrying situation which antagonists promote. Table 4
Agreement to surrogacy i. ii.
For defined medical reasons Forbidden in all circumstances
Doctors
Patients
57% 35%
79% 15%
It is inevitable that fertility specialists will receive some requests for surrogacy and there is therefore a need for them to be fully aware as to whether treatment is possible in practical and in legal terms. I have consulted professors oflaw and solicitors in
12
Medico-Legal Journal 58/1
order to understand whether one could proceed with a medical request in certain defined situations, e.g. following hysterectomy for gynaecological cancer, etc. One opinion indicated that "The Surrogacy Arrangement Act is a crude blunderbuss which has sprayed its shot effect so widely as, in my view, to catch professional advisers if they get involved for a fee. The Act forbids any person, on a commercial basis, from initiating or taking part in any negotiations with a view to the making of a surrogacy arrangement. It is impossible to give any clear legal advice, save to say that potentially there is an awful risk". This present position is quite unsatisfactory. The uncertainty surrounding surrogacy indicates the importance of ensuring that future legislation relating to reproductive function does not positively discriminate against some deserving patients.
Legislation Five years have now elapsed since the publication of the Warnock Report (1984). The medical profession remains uncertain as to exactly what will be encompassed in the intended new legislation. We now await the results of a free vote of MPs as to whether research on human embryos should be allowed for up to 14 days or totally prohibited. Ifthe latter results the UK will no longer be able to pioneer developments which might result in more successful fertility treatment and the elimination ofgenetic disease. It is an obvious irony that those against research on embryos do not also appreciate that its very institution could result in a lower incidence of termination of pregnancy either from the development of new contraceptive strategies or by developing new techniques which might identify which oocytes or embryos actually do possess the potential viability for human life. The latter would allow more precision as to which oocytes/embryos to transfer and which to freeze or discard. There is certainly much to commend allowing infertile couples to be involved with decisions affecting their treatment including the number ofoocytes or embryos for transfer. It is certainly very difficult to understand why a distant authoritative body should be able to dictate to a given infertile couple about the various parameters of treatment they receive without having any knowledge oftheir individual and specific circumstances. Infertile couples could be excused from considering that those representing society, who make judgments upon their care, might have become mesmerised by some perceptions ofclinical medicine which do not represent the true biological realities oflife. It is quite understandable and laudable that the Interim Licensing Authority (ILA) should be concerned about the risk and sequelae of multiple pregnancy, a concern which I myself share, but in my view not all infertile couples have the same prospect of achieving a pregnancy or having a high order multiple pregnancy. The setting down ofa fixed limit to the number ofoocytes or embryos for transfer, in the absence, or presence, oflegislation, will mean that some infertile couples will be positively discriminated against in terms of the success of treatment. Figure 1 shows that the incidence ofpregnancy and miscarriage occuring in 1,071 patients treated by the GIFT technique is significantly influenced by the age of the
AssistedConception
13
Figure 1
Pregnancy and Abortion Rates in 1071 First GIFT Treatment Cycles
50 45 P E R C E N T
40
_
35
%PREGN
-%ABORTED
30 25 20 15 pregnancy
It is also a fact that women whose partners have sperm oflow motility have a lower chance of achieving a pregnancy and a lower incidence of multiple pregnancy, than when more favourable sperm is available (Table 6). In essence, women whose husbands have low motility require more eggs to be transferred to achieve comparable pregnancy rates without a significant risk of multiple pregnancy. These two examples serve to indicate that regulatory authorities should become familiar with the biological realities ofreproduction and refrain from being specific about clinical decisions. Freedom to practise medicine in the best interest of the patient is essential and applies equally to reproductive medicine as to every other discipline. Ofcourse society does require certain overriding constraints to be in operation but the major need for these concerns controls on research on human embryos, especially since society already has in operation an analogous situation where the Home Office monitors experimentation performed upon animals.
Recommendations Certain recommendations should be considered prior to legislation being enacted. 1. 2. 3.
4.
The setting up of a new independent advisory body to consider the various medico-legal concerns of reproductive medicine. Clarification as to who has legal jurisdiction over the use, storage and disposal of gametes and embryos. A recommendation that individuals and couples should make a clear indication about the use, storage and disposal of gametes/embryos at the time of generation! production. Ensuring that patients are really consulted about the use, storage and disposal of gametes, embryos.
15
AssistedConception 5. 6. 7.
Ensuring that patients are involved with decisions affecting their treatment and that these decisions should be flexible to accommodate individual needs. Trying to ensure that any legal uncertainties are resolved without the need for prosecution of an individual doctor or lawyer. Ensuring that all personal data concerning patients (present and retrospective) remains confidential.
With regard to the future new Statutory Licensing Authority (SLA) I would recommend that: 1. 2. 3. 4. 5.
The structure, representation and accountability be well organised. There should be representation of the views ofpatients, doctors, lawyers, and lay public, nurses, religious views, etc. It does not become a bureaucratic and rigid central organisation but is able to divest its executive powers locally to ethics committees of fertility units and scientific centres. All identifying information and personal data remains confidential. An inspectorate has free access to research centres and to the data thereof.
Hopefully, consideration ofthe above might result in increased public confidence and ultimately in better results of clinical treatment. Discussion Chairman: Thankyou. Ladiesand Gentleman, a very large numberof pointshave been raised, so who wants to start the questioning? Dr. J Pym (GeneralPractitioner):I am gladthat the word "happiness" appeared in your penultimate slide. How much happiness and how much unhappiness iscreatedfor people?Obviously those whosucceedingettingpregnantare veryhappybut how about those who fail? I recently had a patient wherethehusbandinfactwalkedoutonhis wifeas a resultof theseinvestigations becomingavailable and, after what the couple went through, it failed. I suspectthat ifthese advanceshad notbeenmade, neithersidewouldhave knownwhichof them was infertileandtheymighthaveacceptedit withmore happiness. Professor Craft: That is an extraordinarily profound questionand I do not think that I can do it adequatejustice in a very short time. You are correctin assuming thatthemajority do notsucceed withtheir first attempt at treatment, and one does not know for certain that they will ever do so. However, I think if one is responsible enough to explain to the couple at the very beginning what factorsinfluencesuccess,thenit allowsthemto get their treatment into some sort of perspective, knowingthata 25-year-oldwomanonlyhasa 25 % of becoming pregnant in any natural cycle. Of course we do need to communicate closely with
general practitioners at the time that treatment is being undertaken just in order to support those couples who inevitably will not succeed. This particularaspectof care is difficultto organiseand inevitably some unhappiness is bound to occur. Manywill feelthat it is betterto do somethingthan to do nothing. I consider that despite the many limitationsof assisted conceptiontreatment, considerable happiness has been brought to many coupleswho wouldnot haveotherwiseachieveda pregnancy, and the fact that some succeed is a stimulusto improvewhatinevitablywillbe seenin retrospect to be the relativelycrude technologyof this present day. Mr. Jeremy Wright (Gynaecologist): Does it worry you, as it worries me, that you can only get competentinfertilitytreatmentifyoucanpayforit? Professor Craft: Yes,itdoesworryme. Ourfirst testtubebabieswerebornin 1982and onlyoccurred becauseof thededicationof a smallgroupof people whowantedittooccur. The patientsfromStockport in Manchester w.ere treated as National Health Servicepatientsat the RoyalFree Hospital, where I formerly held an appointment. The provision of a service is dependent on a specialist having an interest in the subject and more importantly the organisationof a supportiveteam. Obviouslywith limited resources the NHS is unable to make a comprehensive commitment but in my opinion
16 manythings are possible to achieve by unconventionalmeanssuchasthedeployment ofexisting staff who are ableto learn new skills, e.g. embryology, ultrasound, etc. Whilst we have always been supportive of the idea that each regional health authority should have a reproductive medicine centre, it may well be that liaison between the privateand NHS sectorscouldensurefor a greater availability of services even for NHS patients. Whilstit wouldbe relatively expensive for the NHS to set up de novoanassistedconception programme undertaking twotreatments perday, itcouldbecost effectiveto contractthis work to a private hospital at discretionary rates ratherthanhavetheprofound expense of setting up a purpose-builtcentre. Mr. Leigh (Lawyer): I was prompted by your answer to the first question that you were asked. ProfessorCraft, did I understandyou to say that in the majority of cases your treatment makes your patients more unhappythan when they came? Professor Craft: No, not at all. Mr. Leigh: I thought that you accepted that the treatment was successful in a minority of cases. Professor Craft: If you reflect on the 1,071 patients treated by the GIFT technique, 33 % became pregnant so obviously 67 % did not. Of those having a second attempt at treatment, approximatelyone-thirdbecamepregnant, and so on. It is impossible for any fertility technique to yield 100% success. I have explained the likely successof natural fertilityin a 25-year-oldwoman and it is necessaryto explainto prospectivepatients that they may not succeedwith their first attempt. I do not think that is irresponsible; it is just being factual. Mr. Leigh: I am sorry. I do apologise. I did not suggestat all that it was irresponsible, but is it the case that the majority do not become pregnant? Professor Craft: No, itis notnecessarily thecase that the majority do not become pregnant. It dependsonthepopulation thatyoutreat. Ifyouwere toask methequestion" Are women45 yearsof age or olderlikelytoachievea pregnancywithrepeated treatment?" then the answer is simply "No, they are not". The majoritywillnotgetpregnant. If you were to ask methe question' 'Would it be possible to get higher success rates for some people by certainmanoeuvres?", then the answeris "Yes". If oocytesaredonatedbyyoungerwomenand made available to women over the age of 40, then a successrateofsome40% canbepredicted, i.e, you givetheolderwomenthepotentialof thatnormally inherentinthoseofyoungeryears.Indeed,theolder woman has an increased risk of becoming too pregnantwitha resultantmultiplepregnancy, so in responsetoyourquestion itdependsonexactlywhat
Medico-LegalJourna158/1 population youtreatandthebiological variables that exist. Mrs. Susan Garnett (Barrister): I have had seventries, I think,at theIVFprocedure. Professor Craft, can youexplain whythe ILA have notbeen interestedin havinga lay member, albeitinfertile, actually sitting on the ILA? Professor Craft: Not very easily, no. The main concern of the ILA has beento reassure the public that the profession (MRC/RCOG) is able to superviseresearchon humanembryos. However, they have been particularlyconcernedaboutsome of the other aspects of fertility treatment that we have discussed and especially that their exposure might result in the British public becoming less receptive to the need for research on human embryos. In my viewthis has led to a confusionof anxieties andpriorities. I gainedtheimpression that the ILA has very much wanted a regimented and unified approach on all of the issues involved, including the number of eggs and embryos for transfer, and that an articulatepersonlikeyourself could encourage differing opinions within the Committee. My own view is that, as a member of thepublic,youshouldhavea voicein thetreatment you receive since you would expect this in every other aspect of medicine. I also feel that infertile couples should be represented on the ethics committees of fertility units. Mrs. Garnett: One could be quite confused between the ill and the infertile. I can understand thatyoudo consultthe sickasto howyoutreatthem but the infertile are not in that position. Professor Craft: One of the problems is that infertile couplesasa grouphavedifficulty inmaking appropriate representation. Miss Julia Stone (Lawyer): Even with the current very low rate of success,to whatextentdo you promoteacceptanceof childlessness as part of yourcounselling? Yousaidthatcounselling isvery important. Do you think perhaps that if this was somethingthat was promotedfewerpeoplewould perhapsbe bankruptingthemselvescurrentlytogo through treatment? Professor Craft: I thinkweshouldtry andensure that this does not happen, since it causes obvious offence. We do have counselling facilities both withinthedepartmentandanabilityto sendcouples to an outside independentcounsellor, if the latter wasthoughtto be in their bestinterests.I alsothink there has to come a time when people will accept childlessness. This timewilldifferfrom individual to individualand it dependshow far an individual couplewantto pursuethe fertilityoption. Inability to achieve a pregnancy using their own gametes could mean the end of the road as far as predicted
AssistedConception success is concerned, but changing a biological parameter, i.e. the provision of donating gametes, could totally change matters if this is something a couple would wish to consider. So your question is very difficult to answer since it depends on individual circumstances. Counselling, as recommended by the ILA, is absolutely essential and there has to come a time when infertile couples stop receiving treatment. Dr. Fitzgibbon: You said that the conceptus has potential for life. Did you say that only occurred once the conceptus implanted? Professor Craft: It only has a realistic potential once implanted. Dr. Fitzgibbon: I accept that; but what about selective reduction? If you say once it is implanted, surely some qualitative difference has occurred here and if you selectively reduce I feel that this amounts to abortion. Professor Craft: I did not say that it did not amount to abortion. I amjust saying that there are these different opinions. I am not in a position of trying to promote it. My view about it is that there are certain medical situations whereby it needs to be entertained and you really cannot stand back as a doctor and not consider it. You can say that you will not be involved with it and ask the patient to go to seek another doctor's advice, but you really cannot stand back and say "I will not consider it". I am concerned that as a profession we are becoming somewhat hypocritical, whereby we turn a blind eye to the performance of 170,000 abortions each year, most of them for social reasons, and yet we are unduly concerned about the performance ofless than 100 selective reductions each year for defined medical reasons. It is going to be most unfortunate if a particular doctor will have to be prosecuted to sort out a medico-legal dilemma. It is illogical to me to put the life of a woman at risk. Mrs. Diana Brahams: Icanputyourmindjust a little at rest because if you look at the judgment in Bourne, the best known of any abortion case, the judge said that doctors must be prepared to take the life of the fetus if its continued existence put the mother's life at serious risk - doctors who could not entertain that should not be practising in obstetrics. He said you do not wait until the mother's life is desperately threatened and that you should - not only that you can - intervene, and
17 that! think must go for selective reduction as well. To my mind, that is abortion. Whether or not that is covered by a tiny green corner of the Abortion Act is a matter ofdebate. I think that you are better off complying with the provisions of the Act than not doing so. At least you have done everything that you can. Mr. Alec Samuels (Lawyer): As I understand it, my genetic structure, my genetic inheritance, derives from my biological father, the man who provided the sperm, and from my biological mother, the woman that provided the egg. I have, do I not, a human right to know my biological parents and as soon as you start introducing third parties we get anonymity, deception and confusion, and are we not in danger of putting the gratification of adults before the dignity of children? Professor Craft: You have a valid point there. I think think it is perfectly possible for infertile couples to bring up children that have come from donated gametes and to give them good homes and for them to be wanted children who are ultimately told that they resulted from the donation of a sister's egg or from an anonymous donor. I do not see that it is necessarily wrong. I do not think it will cause any harm, and you have to reflect upon the fact that a considerable number of children think that their father is their biological father when in fact that is notthe case. This is the reality oflife and they are not necessarily any the worse for it as children. Infertility really is a profound problem and I think that if people elect to use donated sperm because they were unfortunately born without any speprm, then what is necessarily very wrong about it? I do not see anything very wrong about it at all, I must say. The Chairman: Ladies and Gentlemen, time has now crept upon us. During the lecture I was making notes ofpotential questions, as one does, in case we had a terrible hiatus where nobody said anything when we asked for further questions. The first thing is that the number of jottings that I have made around the edges of this piece ofpaper show quite clearly the range of the lecture that we have been given tonight, and that fact that I have not had an opportunity to ask a single question just shows the interest in the audience. Professor Craft, we are extremely grateful to you. Thank you very much indeed.
THE MEDICO-LEGAL SOCIETY A meeting ofthe Medico-Legal Society was held on Thursday 9 February 1989. The President, DrJ.D.K. Burton, was in the Chair.
ASSISTED CONCEPTION by Professor IAN CRAFT, FRCS, FRCOG, Head of the Fertility & IVF Unit, Humana Hospital Wellington, London, NW8 9LE THE DEVELOPMENT ofadvances in fertility, particularly those occurring in the last decade as the result of assisted conception treatment, has brought with it a plethora of public anxieties. Assisted conception, i.e. that occurring other than by natural intercourse following medical treatment, now embraces methods which have been designated with an ever-increasing number of acronyms, e.g. AI, DIPI, lUI, IVF/ET, GIFT, 21FT, etc. In essence, the basic concept behind each has been an attempt to ensure that a sample of semen is appropriately processed so that sperm are potentially capable offertilising eggs (oocytes) at a time when the latter are about to be released from the ovary. This may occur either naturally following release of nature's own stimulus (luteinising hormone - LH) or following a surrogate stimulus achieved by the administration ofhuman chorionic gonadotrophin (HCG). Oocyte development may either occur naturally, usually with the release ofa single oocyte, or following drug induction, using agents to promote the developments ofmultiple oocytes. This may be achieved either by administering injections ofgonadotrophins which raise the threshold of stimulation or by administering tablets, e.g. clomiphene citrate, which result in the pituitary gland secreting more endogenous gonadotrophins. These agents are frequently used in combination. Different women exhibit varying potentials of response to such agents, some making cohorts of few oocytes and others making cohorts of many. The oocytes produced are usually of varying grades of maturity and have differing potentials for both fertilisation and the development of embryos which themselves have different abilities to implant. The assisted conception methods most commonly used include artificial insemination (AI), now most usually performed using washed sperm injected directly into the uterine cavity, i.e. intrauterine insemination (lUI). In-vitro fertilisation and embryo transfer (IVF/ET) consists of fertilising oocytes, recovered either by laparoscopy or by ultrasound methods, in a defined culture medium in an incubator at 37°C with prepared sperm, and subsequent transfer of some, or all, of the resultant embryos into the uterus via the cervical canal some 24-48 hours later. Gamete intrafallopian transfer (GIFT) consists of transferring oocytes and sperm into one or both open fallopian tubes by laparoscopy at the actual time ofoocyte recovery so that fertilisation occurs in-vivo, as opposed to in-vitro, with IVF. Why then has assisted conception technology become the subject of such emotive feeling in the community since the first test-tube baby was born in 1978? In my view this has in part been due to the public becoming aware of differences of opinion
8
Medico-LegaLJouma158/1
between doctors and scientists, some of whom have used the media to be critical of their colleagues' points of view, rather than direct such comments to the editorial columns ofthe BMJ or Lancet. It would certainly be preferable ifmore attention was given to using the media to provide basic science information for the public on the subject ofearly human development, and on the causes and treatment of infertility. Had this been the case there might have been fewer concerns, and more informed opinion, about the anxieties outlined in Table 1. Table 1
Anxieties Concerning Assisted Conception 1. 2. 3. 4. 5. 6. 7.
Research on human embryos* The use of donated oocytes, sperm, embryos The cryopreservation of oocytes, sperm, embryos The use of known/anonymous donors* The risk and sequelae of multiple pregnancy* Selective reduction of pregnancy* Surrogacy
Those marked with an asterisk have provoked the greatest reaction especially as the surrogacy issue has received less attention following implementation of the Surrogacy Arrangements Act, 1985. The reaction to these different issues depends on whether one is infertile, a member of the medical and scientific community, or an uninvolved member of the general public. In most instances people are either generally for or against an issue as they perceive it, even allowing for the fact that they frequently do not fully understand the biological realities of human life which have relevance to the issue concerned. To many people (including lawyers) a human embryo is considered synonymously with an unborn child and yet a human conceptus consisting ofa mass ofcells cannot even start to differentiate to a formative embryo and placenta until after successful implantation has occurred, i.e. many days after fertilisation. Many human embryos generated both naturally and after fertility treatment exhibit chromosome and other structural abnormalties which preclude normal development and therefore could not possibly lead to a child being born. Therefore many anxieties and views are based upon total misconceptions about the realities oflife itself and are probably influenced by one's upbringing, religious view, etc. These considerations do not preclude the concept that there should be respect for human embryos and their potential for life. In order to try to assess the main anxieties of infertile patients and their referring doctors - both GPs and specialists, Miss Elly Fincham from our Department conducted a questionnaire/survey ofthese two groups and evaluated the responses from approximately 1,000 infertile couples and 200 doctors.
Research on human embryos Table 2 shows that ofthe four major concerns, infertile couples were most worried about research being performed on human embryos, whilst this was the second major
9
Assisted Conception
concern of doctors. Of the latter, 64% considered embryos should be made specifically available for research after fertilisation ofdonated oocytes from normal fertile volunteers, and yet 19 % thought the research should be performed on embryos left over from a given couple's treatment cycle, even though they may have been available for that couple's future benefit. Table 2
Major anxieties of assisted conception Research on human embryos ii. Anonymity of donor gametes iii. Risk and sequelae of multiple pregnancy iv. Selective reduction of pregnancy
1.
Doctors 33 %
Patients 69 %
8% 45 % 8%
1% 17 % 5%
Only 5 % ofinfertile couples wanted their excess embroyos to be used for research and 70 % wished them to be frozen for their potential future use. However, 20 % were happy to consider that their excess embryos might be available for the benefit of another infertile couple. In the event ofmarital break-up or death, 64 % wanted their embryos to be donated to other infertile couples and only 10% wanted them to be used for research or to be thawed without use. The fact that so few couples wish to have their embryos used for research, when offered other realistic alternatives such as cryopreservation, questions whether it is morally correct to undertake research on human embryos of infertile couples. Some fertility units do not have active freezing programmes for resultant excess embryos so the choice of disposal is limited. The recent government White paper (items 50,51) indicated that the "storage authority" should not have the right ofuse, or disposal, ofoocytes/embryos unless specifically granted this by the donor - a view which I support. However, the question as to who owns oocytes, sperm, and embryos remains unanswered in legal terms. Indeed, women appear to have no legal rights over the use and disposal oftheir own oocytes/embryos, even though they have the right to affect their reproductive function in other ways, e. g. by hysterectomy, sterilisation and therapeutic abortion.
Oocyte donation Table 3 indicates the response of infertile couples and doctors to a question concerning the anonymity of donors. Very few thought that the donor should always be known. There was a greater suport for having a flexible policy to suit individual circumstances from patients than their referring doctors.. The view expressed by the Interim Licensing Authority (ILA) is that known donors should not be used on the assumption that this may be associated with a high incidence of subsequent emotional and other problems for offspring resulting from such treatment. However, it is my view that known donors should be available in certain situations after appropriate counselling and screening. It seems extremely unfair and illogical for society to insist that a sister may not receive the oocytes ofher own biological sister, thereby ensuring she has her own genetic background. In some cultures it is the practice for some
10
Medico-Legal Joumal 58/1
infertile couples to receive children from their fertile relatives to circumvent childlessness. This practice is rarely associated with adverse sequelae and it would bean unfortunate situation if the proposed Statutory Licensing Authority (SLA) make the recommendation that donors should always beanonymous into an inflexible and definitive rule. Table 3
Anonymity of donors i. The donor should always be anonymous ii. The donor should always be known iii. Donors may be known or anonymous to suit different circumstances
Doctors 52% 3%
Patients 25% 2%
38%
69%
The government White paper (item 80) indicated that where a child results from treatment using donated gametes or embryos, the carrying mother shall be regarded in law as the child's mother, which I support. However, the medical profession and patients alike have anxieties about another recommendation (item 84) that it may be possiblefor children born following gamete donation to be granted access to identifying information which may become retroactive.
Selective reduction of pregnancy This subject, although not considered a major concern by infertile couples and doctors, has preoccupied the ILA and because of their concern the media have given it an undue amount of attention. Even so, 55 % of doctors interviewed thought this practice should beallowed for specific medical indications and 31 % thought it should be available at a given patient's request. Only 9% of doctors thought it should be prohibited. The reason why it has come into prominence at all stems from the fact that, although it has been performed in the U.K. for a decade or more for the elimination of fetal abnormality, usually in the mid-trimester, it is now possible to reduce a multiple pregnancy to a lower order in the first trimester because of developments in imaging techniques. Another reason for its notoriety is based upon uncertainties as to its position in law, even allowing for the fact that it has been performed as a routine service at King's College Hospital in London for many years without the specialists invoking the Abortion Act until recently. Doctors have acted in good faith and the Royal College of Obstetricians and Gynaecologists (RCOG) and the Department of Health (DHSS) must have been aware of its use without proferring advice on the medico-legal uncertainties. The Life Organisation has taken advantage of the uncertain medico-legal position by making a request that the DPP investigate individual doctors in the hope that a prosecution would result in a successful conviction and thereby indirectly lead to a change in the 1967 Abortion Act. Some of the differences between the view ofclinicians and lawyers on this subject have been based upon the understanding, or misunderstanding, of semantics. Doctors
AssistedConception
11
consider that a woman is pregnant if she exhibits features of pregnancy and this condition is not necessarily synonymous with her' 'being with child" . Consequently, to many doctors it is not possible for a woman to be multiply pregnant; she either exhibits the features ofpregnancy or not. Similarly, a lawyer may consider selective reduction of pregnancy may result in a partial miscarriage which is a condition unrecognised by clinical doctors. Miscarriage is either complete or incomplete, and the latteris frequently associated with sepsis, if unattended to. Therefore, in general parlance it is not possible to have a partical miscarriage. Legal opinions obtained by the DHHS, RCOG and individual fertility specialists on this subject have provided differing advice. While most have indicated that the Abortion Act covers this technique, the QC's opinion obtained on behalf of my medical defence society (Medical Protection Society) indicated that: i)
Selective reduction of pregnancy may be an Offence against the Persons Act, 1861 ii) The Abortion Act, 1967, may not be capable of affording protection and iii) There may be a possible risk under the Infant Life (Preservation) Act 1929.
It would be most unfortunate if a doctor was prosecuted in order to clarify a medicolegal uncertainty, especially when the practice of selective reduction ofpregnancy has been used, albeit rarely, for defined medical indications for so long now, with responsible authorities being in full knowledge of that fact.
Surrogacy The Surrogacy Arrangements Act, 1985, was enacted soon after the birth of baby Cotton which evoked emotive media coverage and hasty legislation. The Act has led to a number ofuncertainties and as a consequence, doctors and lawyers are both under potential threat of prosecution if they accept a fee for giving professional advice to prospective clients, irrespective ofthe fact that they are not in essence involved with making any surrogate arrangement. This situation is to be regretted since there was no need for such hasty action. More informed debate and discussion could have resulted in better legislation. Although the number of infertile couples requiring surrogacy is extremely small, their medical problems nevertheless remain profound. Surrogacy need not be the worrying situation which antagonists promote. Table 4
Agreement to surrogacy i. ii.
For defined medical reasons Forbidden in all circumstances
Doctors
Patients
57% 35%
79% 15%
It is inevitable that fertility specialists will receive some requests for surrogacy and there is therefore a need for them to be fully aware as to whether treatment is possible in practical and in legal terms. I have consulted professors oflaw and solicitors in
12
Medico-Legal Journal 58/1
order to understand whether one could proceed with a medical request in certain defined situations, e.g. following hysterectomy for gynaecological cancer, etc. One opinion indicated that "The Surrogacy Arrangement Act is a crude blunderbuss which has sprayed its shot effect so widely as, in my view, to catch professional advisers if they get involved for a fee. The Act forbids any person, on a commercial basis, from initiating or taking part in any negotiations with a view to the making of a surrogacy arrangement. It is impossible to give any clear legal advice, save to say that potentially there is an awful risk". This present position is quite unsatisfactory. The uncertainty surrounding surrogacy indicates the importance of ensuring that future legislation relating to reproductive function does not positively discriminate against some deserving patients.
Legislation Five years have now elapsed since the publication of the Warnock Report (1984). The medical profession remains uncertain as to exactly what will be encompassed in the intended new legislation. We now await the results of a free vote of MPs as to whether research on human embryos should be allowed for up to 14 days or totally prohibited. Ifthe latter results the UK will no longer be able to pioneer developments which might result in more successful fertility treatment and the elimination ofgenetic disease. It is an obvious irony that those against research on embryos do not also appreciate that its very institution could result in a lower incidence of termination of pregnancy either from the development of new contraceptive strategies or by developing new techniques which might identify which oocytes or embryos actually do possess the potential viability for human life. The latter would allow more precision as to which oocytes/embryos to transfer and which to freeze or discard. There is certainly much to commend allowing infertile couples to be involved with decisions affecting their treatment including the number ofoocytes or embryos for transfer. It is certainly very difficult to understand why a distant authoritative body should be able to dictate to a given infertile couple about the various parameters of treatment they receive without having any knowledge oftheir individual and specific circumstances. Infertile couples could be excused from considering that those representing society, who make judgments upon their care, might have become mesmerised by some perceptions ofclinical medicine which do not represent the true biological realities oflife. It is quite understandable and laudable that the Interim Licensing Authority (ILA) should be concerned about the risk and sequelae of multiple pregnancy, a concern which I myself share, but in my view not all infertile couples have the same prospect of achieving a pregnancy or having a high order multiple pregnancy. The setting down ofa fixed limit to the number ofoocytes or embryos for transfer, in the absence, or presence, oflegislation, will mean that some infertile couples will be positively discriminated against in terms of the success of treatment. Figure 1 shows that the incidence ofpregnancy and miscarriage occuring in 1,071 patients treated by the GIFT technique is significantly influenced by the age of the
AssistedConception
13
Figure 1
Pregnancy and Abortion Rates in 1071 First GIFT Treatment Cycles
50 45 P E R C E N T
40
_
35
%PREGN
-%ABORTED
30 25 20 15 pregnancy
It is also a fact that women whose partners have sperm oflow motility have a lower chance of achieving a pregnancy and a lower incidence of multiple pregnancy, than when more favourable sperm is available (Table 6). In essence, women whose husbands have low motility require more eggs to be transferred to achieve comparable pregnancy rates without a significant risk of multiple pregnancy. These two examples serve to indicate that regulatory authorities should become familiar with the biological realities ofreproduction and refrain from being specific about clinical decisions. Freedom to practise medicine in the best interest of the patient is essential and applies equally to reproductive medicine as to every other discipline. Ofcourse society does require certain overriding constraints to be in operation but the major need for these concerns controls on research on human embryos, especially since society already has in operation an analogous situation where the Home Office monitors experimentation performed upon animals.
Recommendations Certain recommendations should be considered prior to legislation being enacted. 1. 2. 3.
4.
The setting up of a new independent advisory body to consider the various medico-legal concerns of reproductive medicine. Clarification as to who has legal jurisdiction over the use, storage and disposal of gametes and embryos. A recommendation that individuals and couples should make a clear indication about the use, storage and disposal of gametes/embryos at the time of generation! production. Ensuring that patients are really consulted about the use, storage and disposal of gametes, embryos.
15
AssistedConception 5. 6. 7.
Ensuring that patients are involved with decisions affecting their treatment and that these decisions should be flexible to accommodate individual needs. Trying to ensure that any legal uncertainties are resolved without the need for prosecution of an individual doctor or lawyer. Ensuring that all personal data concerning patients (present and retrospective) remains confidential.
With regard to the future new Statutory Licensing Authority (SLA) I would recommend that: 1. 2. 3. 4. 5.
The structure, representation and accountability be well organised. There should be representation of the views ofpatients, doctors, lawyers, and lay public, nurses, religious views, etc. It does not become a bureaucratic and rigid central organisation but is able to divest its executive powers locally to ethics committees of fertility units and scientific centres. All identifying information and personal data remains confidential. An inspectorate has free access to research centres and to the data thereof.
Hopefully, consideration ofthe above might result in increased public confidence and ultimately in better results of clinical treatment. Discussion Chairman: Thankyou. Ladiesand Gentleman, a very large numberof pointshave been raised, so who wants to start the questioning? Dr. J Pym (GeneralPractitioner):I am gladthat the word "happiness" appeared in your penultimate slide. How much happiness and how much unhappiness iscreatedfor people?Obviously those whosucceedingettingpregnantare veryhappybut how about those who fail? I recently had a patient wherethehusbandinfactwalkedoutonhis wifeas a resultof theseinvestigations becomingavailable and, after what the couple went through, it failed. I suspectthat ifthese advanceshad notbeenmade, neithersidewouldhave knownwhichof them was infertileandtheymighthaveacceptedit withmore happiness. Professor Craft: That is an extraordinarily profound questionand I do not think that I can do it adequatejustice in a very short time. You are correctin assuming thatthemajority do notsucceed withtheir first attempt at treatment, and one does not know for certain that they will ever do so. However, I think if one is responsible enough to explain to the couple at the very beginning what factorsinfluencesuccess,thenit allowsthemto get their treatment into some sort of perspective, knowingthata 25-year-oldwomanonlyhasa 25 % of becoming pregnant in any natural cycle. Of course we do need to communicate closely with
general practitioners at the time that treatment is being undertaken just in order to support those couples who inevitably will not succeed. This particularaspectof care is difficultto organiseand inevitably some unhappiness is bound to occur. Manywill feelthat it is betterto do somethingthan to do nothing. I consider that despite the many limitationsof assisted conceptiontreatment, considerable happiness has been brought to many coupleswho wouldnot haveotherwiseachieveda pregnancy, and the fact that some succeed is a stimulusto improvewhatinevitablywillbe seenin retrospect to be the relativelycrude technologyof this present day. Mr. Jeremy Wright (Gynaecologist): Does it worry you, as it worries me, that you can only get competentinfertilitytreatmentifyoucanpayforit? Professor Craft: Yes,itdoesworryme. Ourfirst testtubebabieswerebornin 1982and onlyoccurred becauseof thededicationof a smallgroupof people whowantedittooccur. The patientsfromStockport in Manchester w.ere treated as National Health Servicepatientsat the RoyalFree Hospital, where I formerly held an appointment. The provision of a service is dependent on a specialist having an interest in the subject and more importantly the organisationof a supportiveteam. Obviouslywith limited resources the NHS is unable to make a comprehensive commitment but in my opinion
16 manythings are possible to achieve by unconventionalmeanssuchasthedeployment ofexisting staff who are ableto learn new skills, e.g. embryology, ultrasound, etc. Whilst we have always been supportive of the idea that each regional health authority should have a reproductive medicine centre, it may well be that liaison between the privateand NHS sectorscouldensurefor a greater availability of services even for NHS patients. Whilstit wouldbe relatively expensive for the NHS to set up de novoanassistedconception programme undertaking twotreatments perday, itcouldbecost effectiveto contractthis work to a private hospital at discretionary rates ratherthanhavetheprofound expense of setting up a purpose-builtcentre. Mr. Leigh (Lawyer): I was prompted by your answer to the first question that you were asked. ProfessorCraft, did I understandyou to say that in the majority of cases your treatment makes your patients more unhappythan when they came? Professor Craft: No, not at all. Mr. Leigh: I thought that you accepted that the treatment was successful in a minority of cases. Professor Craft: If you reflect on the 1,071 patients treated by the GIFT technique, 33 % became pregnant so obviously 67 % did not. Of those having a second attempt at treatment, approximatelyone-thirdbecamepregnant, and so on. It is impossible for any fertility technique to yield 100% success. I have explained the likely successof natural fertilityin a 25-year-oldwoman and it is necessaryto explainto prospectivepatients that they may not succeedwith their first attempt. I do not think that is irresponsible; it is just being factual. Mr. Leigh: I am sorry. I do apologise. I did not suggestat all that it was irresponsible, but is it the case that the majority do not become pregnant? Professor Craft: No, itis notnecessarily thecase that the majority do not become pregnant. It dependsonthepopulation thatyoutreat. Ifyouwere toask methequestion" Are women45 yearsof age or olderlikelytoachievea pregnancywithrepeated treatment?" then the answer is simply "No, they are not". The majoritywillnotgetpregnant. If you were to ask methe question' 'Would it be possible to get higher success rates for some people by certainmanoeuvres?", then the answeris "Yes". If oocytesaredonatedbyyoungerwomenand made available to women over the age of 40, then a successrateofsome40% canbepredicted, i.e, you givetheolderwomenthepotentialof thatnormally inherentinthoseofyoungeryears.Indeed,theolder woman has an increased risk of becoming too pregnantwitha resultantmultiplepregnancy, so in responsetoyourquestion itdependsonexactlywhat
Medico-LegalJourna158/1 population youtreatandthebiological variables that exist. Mrs. Susan Garnett (Barrister): I have had seventries, I think,at theIVFprocedure. Professor Craft, can youexplain whythe ILA have notbeen interestedin havinga lay member, albeitinfertile, actually sitting on the ILA? Professor Craft: Not very easily, no. The main concern of the ILA has beento reassure the public that the profession (MRC/RCOG) is able to superviseresearchon humanembryos. However, they have been particularlyconcernedaboutsome of the other aspects of fertility treatment that we have discussed and especially that their exposure might result in the British public becoming less receptive to the need for research on human embryos. In my viewthis has led to a confusionof anxieties andpriorities. I gainedtheimpression that the ILA has very much wanted a regimented and unified approach on all of the issues involved, including the number of eggs and embryos for transfer, and that an articulatepersonlikeyourself could encourage differing opinions within the Committee. My own view is that, as a member of thepublic,youshouldhavea voicein thetreatment you receive since you would expect this in every other aspect of medicine. I also feel that infertile couples should be represented on the ethics committees of fertility units. Mrs. Garnett: One could be quite confused between the ill and the infertile. I can understand thatyoudo consultthe sickasto howyoutreatthem but the infertile are not in that position. Professor Craft: One of the problems is that infertile couplesasa grouphavedifficulty inmaking appropriate representation. Miss Julia Stone (Lawyer): Even with the current very low rate of success,to whatextentdo you promoteacceptanceof childlessness as part of yourcounselling? Yousaidthatcounselling isvery important. Do you think perhaps that if this was somethingthat was promotedfewerpeoplewould perhapsbe bankruptingthemselvescurrentlytogo through treatment? Professor Craft: I thinkweshouldtry andensure that this does not happen, since it causes obvious offence. We do have counselling facilities both withinthedepartmentandanabilityto sendcouples to an outside independentcounsellor, if the latter wasthoughtto be in their bestinterests.I alsothink there has to come a time when people will accept childlessness. This timewilldifferfrom individual to individualand it dependshow far an individual couplewantto pursuethe fertilityoption. Inability to achieve a pregnancy using their own gametes could mean the end of the road as far as predicted
AssistedConception success is concerned, but changing a biological parameter, i.e. the provision of donating gametes, could totally change matters if this is something a couple would wish to consider. So your question is very difficult to answer since it depends on individual circumstances. Counselling, as recommended by the ILA, is absolutely essential and there has to come a time when infertile couples stop receiving treatment. Dr. Fitzgibbon: You said that the conceptus has potential for life. Did you say that only occurred once the conceptus implanted? Professor Craft: It only has a realistic potential once implanted. Dr. Fitzgibbon: I accept that; but what about selective reduction? If you say once it is implanted, surely some qualitative difference has occurred here and if you selectively reduce I feel that this amounts to abortion. Professor Craft: I did not say that it did not amount to abortion. I amjust saying that there are these different opinions. I am not in a position of trying to promote it. My view about it is that there are certain medical situations whereby it needs to be entertained and you really cannot stand back as a doctor and not consider it. You can say that you will not be involved with it and ask the patient to go to seek another doctor's advice, but you really cannot stand back and say "I will not consider it". I am concerned that as a profession we are becoming somewhat hypocritical, whereby we turn a blind eye to the performance of 170,000 abortions each year, most of them for social reasons, and yet we are unduly concerned about the performance ofless than 100 selective reductions each year for defined medical reasons. It is going to be most unfortunate if a particular doctor will have to be prosecuted to sort out a medico-legal dilemma. It is illogical to me to put the life of a woman at risk. Mrs. Diana Brahams: Icanputyourmindjust a little at rest because if you look at the judgment in Bourne, the best known of any abortion case, the judge said that doctors must be prepared to take the life of the fetus if its continued existence put the mother's life at serious risk - doctors who could not entertain that should not be practising in obstetrics. He said you do not wait until the mother's life is desperately threatened and that you should - not only that you can - intervene, and
17 that! think must go for selective reduction as well. To my mind, that is abortion. Whether or not that is covered by a tiny green corner of the Abortion Act is a matter ofdebate. I think that you are better off complying with the provisions of the Act than not doing so. At least you have done everything that you can. Mr. Alec Samuels (Lawyer): As I understand it, my genetic structure, my genetic inheritance, derives from my biological father, the man who provided the sperm, and from my biological mother, the woman that provided the egg. I have, do I not, a human right to know my biological parents and as soon as you start introducing third parties we get anonymity, deception and confusion, and are we not in danger of putting the gratification of adults before the dignity of children? Professor Craft: You have a valid point there. I think think it is perfectly possible for infertile couples to bring up children that have come from donated gametes and to give them good homes and for them to be wanted children who are ultimately told that they resulted from the donation of a sister's egg or from an anonymous donor. I do not see that it is necessarily wrong. I do not think it will cause any harm, and you have to reflect upon the fact that a considerable number of children think that their father is their biological father when in fact that is notthe case. This is the reality oflife and they are not necessarily any the worse for it as children. Infertility really is a profound problem and I think that if people elect to use donated sperm because they were unfortunately born without any speprm, then what is necessarily very wrong about it? I do not see anything very wrong about it at all, I must say. The Chairman: Ladies and Gentlemen, time has now crept upon us. During the lecture I was making notes ofpotential questions, as one does, in case we had a terrible hiatus where nobody said anything when we asked for further questions. The first thing is that the number of jottings that I have made around the edges of this piece ofpaper show quite clearly the range of the lecture that we have been given tonight, and that fact that I have not had an opportunity to ask a single question just shows the interest in the audience. Professor Craft, we are extremely grateful to you. Thank you very much indeed.
