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April 8, 2013 | Posted By Jane Jankowski, LMSW, MS

Gamete retrieval after death or irreversible coma ought not to be counted among the many acceptable practices of assisted reproductive technology (ART) because the donor patient’s consent cannot be reasonably verified and there is no possibility to participate in childrearing activities. Although it is possible a case could arise where the patient leaves clear and convincing evidence of the wish to have gametes harvested following a devastating loss of brain function, I will argue that advance directives are still inadequate and decisions will necessarily default to family members who may have complicated feelings and agendas. In terms of intent, the absence of any ability to participate in childrearing should be taken into consideration when evaluating decisions about harvesting gametes from comatose or deceased patients, again placing the decision with the family members who must accept and accommodate these preferences.  Allowing such a practice affirms the irrelevance of participating in rearing one’s offspring, and this may be lead to a slippery slope of diminishing the importance of responsibility in childrearing activities. 

Advance directives provide some insight into what a patient may have wanted in terms of life sustaining treatment and perhaps allocation of organs and/or gametes. To harvest gametes from an individual who will not be able to affirm their intent to serve as donors for a partner may be morally uncomfortable for physicians. Performing a procedure to extend the reproductive liberty of a patient who will never have a role in any resulting child’s life may understandably challenge a provider’s beliefs about how far medicine ought to go in honoring patient or family requests. The role of surrogate decision makers for a patient who lacks capacity is to honor the spirit of advance directives, if not the exact specifications.  Honoring the autonomy of a patient, however; need not extend to the realm of unfulfilled life goals. A patient who stated they wished to donate organs would still have such a request reviewed and consent is sought from the family members in nearly all cases.  Beyond the consideration due the patient, we may also have an obligation to If  we trust the patient’s intent and permission to retrieve gametes after loss of consciousness, can we fully trust the recipients motives are not influenced by grief or secondary gain, such as disability benefit or estate distribution?

In cases where family members insist that the patient would want to be a parent, would want a legacy to be created via post mortem reproduction, this expression of preference cannot be fully honored because the patient will not be able to participate in any parenting activities. The objections to reproduction after death or irreversible unconsciousness include concerns that the child born of such an arrangement will suffer from having only one parent to provide the necessary nurturing and support. This claim seems weak against the backdrop of millions of children living and growing up successfully in single parent households. If the donor were from a sperm or egg bank where living donors knowingly provide gametes for individuals hoping to conceive a child, there is no expectation of rearing the child, but this is known and expected the time the decision to donate is made and presumably without a reciprocal relationship between donor and recipient. If we include the parental obligation of childrearing in our definition of parenthood, the deceased or comatose donor cannot participate in this activity and therefore should not be conferred the same reproductive liberty. The common thread in all of these possible scenarios is that there is an expectation that the donor will not participate in childrearing. Does this create a risk that parenting duties will be viewed as secondary to the right to bear children? Harvesting gametes from individuals with no hope of participating in childrearing with his or her known partner seems to further diminish the importance of the social commitment to raising children.  For those rare cases where there is evidence such a preference exists, it would seem more advisable to have such a patient preserve gametes while healthy rather than trust in harvesting sperm and eggs once one has lost capacity and unable to provide consent or participate in any childbearing or rearing activities. 

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

5 comments | Topics: Advance Directives, Assisted Reproduction, End of Life Care, Patient Autonomy, Reproductive Medicine

Comments

Bonnie Steinbock

Bonnie Steinbock wrote on 04/18/13 12:56 PM

Men sometimes go off to war, leaving behind a pregnant spouse, knowing that they may not return. Presumably a soldier could leave his sperm for his wife to be artificially inseminated, if they had been unable to conceive naturally before he left. A man who undergoes cancer treatment may preserve his fertility through sperm banking. Recognizing the possibility that he may not survive cancer treatment, he and his wife may decide that they would want to go through with their reproductive project, even though he won't be around to help raise their children. If these are permissible scenarios, why take an absolutist position against the retrieval of sperm post-mortem, as opposed to a presumption against?
Stacey Pulk

Stacey Pulk wrote on 04/18/13 7:54 PM

In regards to gamete retrieval postmortem or while in coma should be uncomfortable for a physician, as it is a direct assault on a non-consenting adult as well as a violation of that individuals autonomy. I believe it would be a rare instance that the individual in question would have an advanced directive giving permission for such a procedure. If this were the case, I agree that the child's welfare must be taken into consideration. As we have seen before, there are times when the existence of an advanced directive and patients right to autonomy has been overridden in consideration of the quality of the life of those who will effected by such decisions.
Don Johnson RN

Don Johnson RN wrote on 04/21/13 5:26 PM

I question the heavy reliance here on the connection between parenting duties and reproductive liberty.

In the narrow circumstance of an advance directive that provides clear and convincing evidence of an individual’s intention to allow post mortem or post consciousness reproduction using harvested gametes:

Certainly there are unfortunate medical circumstances where there is no reasonable expectation that an individual will be able to participate in child rearing. But there are also medical circumstances where an individual has diminished ability to participate in child rearing. Should we diminish reproductive liberty in proportion to child rearing capacities in all cases? Or do we only do so when there is no capacity at all to participate in child rearing?

And, if child rearing duties are a relevant consideration, of what moral significance is the timing of gamete harvesting? Why would it be acceptable to attempt post mortem/post consciousness conception if the harvesting was done while the individual is healthy, but not acceptable if the harvesting was done when the individual is comatose or dead? If the relevant consideration is child rearing capacity, that capacity is absent regardless of the time of harvesting.
Don Johnson RN

Don Johnson RN wrote on 04/24/13 9:44 AM

In response to Stacey Pulk's comments:

I agree that it would be a rare instance in which an advance directive addresses postmortem or post-consciousness reproduction. But since that is the scenario described in the original post, that is the basis for my comments.

The original post suggests that "honoring ... autonomy ... need not extend to the realm of unfulfilled life goals." Perhaps. That is a fairly broad (and unsupported) proposition. But in the context of clear and convincing evidence that the deceased or unconscious individual wished for this goal to be accomplished, and partner who is willing to participate in that endeavor, I think it is also not obviously morally objectionable for autonomy to extend to this realm.

Along the same lines, Pulk suggests that there are cases where autonomy has been overridden "in consideration of the quality of life of those affected by [autonomous] decisions." Again, perhaps this is true in some circumstances. But the circumstance here is presumably one where the surviving partner wishes to honor, not deny, the autonomous decision that extends to the realm of unfulfilled life goals.

I see no morally significant differences between the case described here - a single individual who proposes to conceive using the gametes of a partner who, by clear and convincing evidence, wished for that eventuality, and the case of a single individual who proposes to conceive using a gamete donor from a sperm or egg bank.

In neither case is the gamete donor able or expected to participate in child rearing; and, in neither case is the quality of life for the resulting child a controlling consideration.
Don Johnson RN

Don Johnson RN wrote on 04/24/13 9:58 AM

In response to Stacey Pulk's comments:

I agree that it would be a rare instance in which an advance directive addresses postmortem or post-consciousness reproduction. But since that is the scenario described in the original post, that is the basis for my comments.

The original post suggests that "honoring ... autonomy ... need not extend to the realm of unfulfilled life goals." Perhaps. That is a fairly broad (and unsupported) proposition. But in the context of clear and convincing evidence that the deceased or unconscious individual wished for this goal to be accomplished, and partner who is willing to participate in that endeavor, I think it is also not obviously morally objectionable for autonomy to extend to this realm.

Along the same lines, Pulk suggests that there are cases where autonomy has been overridden "in consideration of the quality of life of those affected by [autonomous] decisions." Again, perhaps this is true in some circumstances. But the circumstance here is presumably one where the surviving partner wishes to honor, not deny, the autonomous decision that extends to the realm of unfulfilled life goals.

I see no morally significant differences between the case described here - a single individual who proposes to conceive using the gametes of a partner who, by clear and convincing evidence, wished for that eventuality, and the case of a single individual who proposes to conceive using a gamete donor from a sperm or egg bank.

In neither case is the gamete donor able or expected to participate in child rearing; and, in neither case is the quality of life for the resulting child a controlling consideration.

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BIOETHICS TODAY is the blog of the Alden March Bioethics Institute, presenting topical and timely commentary on issues, trends, and breaking news in the broad arena of bioethics. BIOETHICS TODAY presents interviews, opinion pieces, and ongoing articles on health care policy, end-of-life decision making, emerging issues in genetics and genomics, procreative liberty and reproductive health, ethics in clinical trials, medicine and the media, distributive justice and health care delivery in developing nations, and the intersection of environmental conservation and bioethics.
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