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HIQA Report let government off hook. November 14, 2013

Posted by WorldbyStorm in Abortion, Bioethics, Culture, Irish Politics.
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A very welcome post by Brendan Young, member of Action on X. As Brendan notes “‘Action on X’, which campaigned for legislation based upon the ‘X Case’ – but regards James Reilly’s recent abortion law as unacceptably restrictive. Action on X has the support of the National Women’s Council of Ireland, SIPTU, UNITE the Union, the ICTU Women’s Committee, USI, and the African women’s support network AkiDwa.”

Recent comments by Dr Sam Coulter Smith (Master of the Rotunda maternity hospital) about the strains the hospital is under, and the findings in the recent HIQA Report (into the death of Savita Halappanavar) that our maternity hospital records are not systematically centralised and monitored, highlight the deep problems in the Irish health service. But the HIQA Report, while it revealed problems with the medical care given to Savita Halappanavar, avoided the issue of the law. And there is a risk that the Galway University Hospital medical team, who may have made errors, will be scapegoated for Savita’s death. Yet it is Irish law, including Art. 40.3.3 of the Constitution and the recently-passed Reilly Act on abortion, that continues to pose risks to women – including those going through inevitable miscarriage.

Doctor Peter Boylan hit the nail on the head in saying that the state, through HIQA, did not ask the obvious question in relation to the death of Savita Halappanavar. What impact did the law on terminations have on the actions of the Galway medical team? Would an earlier delivery – a termination of pregnancy – have saved her life? In his opinion it probably would have. HIQA didn’t ask. Why not?

Last year’s HSE Report into Savita’s death raised the legal issues. It said ‘concerns about the law … impacted on clinical professional judgement’. It quoted the consultant obstetrician as saying “If there is a threat to the mothers’ life you can terminate. If there is a potential major hazard to the mothers’ life the law is not clear…. There are no guidelines for inevitable miscarriages.” The same consultant also said: “Under Irish law, if there’s no evidence of risk to the life of the mother, our hands are tied so long as there’s a fetal heart (sic).”

The HSE Report’s Recommendation 4b makes clear that the law restricts clinical decisions, and suggests change: “… We recommend that the clinical professional community, health and social care regulators, and the Oireachtas consider the law including any necessary constitutional change and related administrative, legal and clinical guidelines in relation to the management of inevitable miscarriage… These guidelines should include good practice guidelines in relation to expediting delivery for clinical reasons. We recognise that such guidelines must be consistent with applicable law and that the guidance so urged may require legal change.”

It is also clear that the consultant obstetrician considered a termination when Savita asked for it but felt legally bound to rule it out because there was a fetal heartbeat – even though the demise of the fetus was inevitable. Yet the HIQA Report poses the issue exclusively as management of sepsis – making no suggestion that ‘expediting delivery’ could have been done to avert infection / sepsis in its list of 13 ‘missed opportunities’ to intervene.

Flowing from its enquiries, HIQA’s Recommendation N10 says: “The HSE should develop a national clinical guideline on the management of sepsis… This guideline should incorporate an escalation/referral pathway that includes clinical, legal and ethical guidance for staff at critical clinical points …”

HIQA’s ‘escalation/referral pathway’, by definition, assumes the woman’s health is deteriorating due to sepsis. Recommending ‘… legal and ethical guidance for staff at critical clinical points’ is to accept that a woman must reach a critical condition before termination can be considered – the only issue where the law becomes relevant. Why would a woman, her loved ones or her doctors wish to allow sepsis to develop to such a potentially lethal extent? Yet termination of pregnancy to prevent infection is not considered in HIQA’s Recommendations. The HSE Report is commended in passing, but its key arguments to legislators are glossed over.

By placing the blame for Savita’s death on the consultant obstetrician’s failure to manage sepsis and ignoring the legal restrictions upon her clinical choices, the HIQA Report is letting Fine Gael, Labour, Fianna Fáil and Sinn Féin off the hook. They can all comfortably point to the need for better management of hospitals and / or more resources – all of which are needed. 

The consultant obstetrician may have made errors, but she should not be made the scapegoat for Savita’s death. A fundamental problem in dealing with inevitable miscarriage is that Art. 40.3.3 of the Constitution, and its interpretation by the Supreme Court, effectively preclude termination of pregnancy during miscarriage if there is a fetal heartbeat – until a woman’s life is at risk. This legal restriction on clinical action contributed to Savita’s death and politicians have a responsibility to deal with it.

If the HIQA Report is used to inform the medical guidelines accompanying James Reilly’s abortion law, its focus on management of sepsis will entrench a perverse situation where medical conditions due to pregnancy that are not in themselves life-threatening (eg inevitable miscarriage) must be allowed become life-threatening before it is legal to perform a termination of pregnancy – on a fetus that will die anyway. The same legal restriction that allowed sepsis to develop in Savita Halappanavar will remain.

James Reilly’s abortion law, based upon Art. 40.3.3, codifies this restriction by giving legal protection to the ‘unborn’ from the moment of implantation in the womb until delivery. Such restriction on doctors, which HIQA did not examine, must be removed so that women’s lives can be protected. At minimum, the HSE Recommendations must be acted upon. Both Art. 40.3.3 and Reilly’s abortion law must be repealed.

Sitting on a fence… July 20, 2013

Posted by WorldbyStorm in Bioethics, Irish Politics, Social Policy.
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John Waters was exercised by the nature of the abortion ‘debate’ this last week and complaining that the criticism of Senator Jim Walsh’s speech to the Seanad which graphically sought to outline the abortion process, albeit from the testimony of an US based anti-abortion activist and obstetrician. There’s a whole bunch of reasons why one might query that testimony, not least its somewhat hazy relationship with the general scientific and medical consensus on fetal pain.

Waters argument is worth considering, though I suspect it raises issues that might not be entirely congenial to his position on the issue in the way they work out, and I’ll return to them some other time.

But here’s the thing. There’s a certain element of Waters having his cake and eating it on this for it is notable that in this column he doesn’t follow Walsh’s lead. Now, there’s no onus upon him to do so, but logically if he believes it is an appropriate, no – necessary, approach then it does raise the question as to why he wouldn’t be quite so blunt. After all, he has a public platform, he has a weekly space in a national newspaper, so if he thinks that Walsh is correct…

And this is surprising and good news… June 13, 2013

Posted by WorldbyStorm in Bioethics, Economy, Science, Social Policy, US Politics.
1 comment so far

…from a somewhat unexpected quarter.

The US supreme court has ruled unanimously that natural human genes cannot be patented, a decision that scientists and civil rights campaigners said removed a major barrier to patient care and medical innovation.

Though whether the Court’s view that DNA a “product of nature” may have implications when applied to other areas is an interesting question.

Got to admit… May 7, 2013

Posted by WorldbyStorm in Bioethics, Culture, Feminism, Irish Politics.
3 comments

Jacky Jones in the Irish Times,former HSE regional manager of health promotion, is a voice of reason on a range of issues from private schools through to reproductive rights.

Unfortunately the Protection of Life during Pregnancy Bill 2013 will not protect or vindicate women’s reproductive rights. The name change – removing the word “maternal” from the title – means there is still ambiguity about whether the woman’s life or that of the foetus is prioritised. It is only a matter of time before another Irish woman asks the European Court of Human Rights to protect and vindicate her right to terminate a pregnancy because her health, as distinct from her life, is not protected by the proposed legislation. In the meantime, Irish women will have to rely on the kindness of strangers in the UK.

Very true.

Terminology… January 18, 2013

Posted by WorldbyStorm in Bioethics, Social Policy, Uncategorized.
7 comments

I’m interested in what people think about this, a piece by Kate Roiphe on Slate where she discusses the impending change by Planned Parenthood in the US from the term pro-choice to some, as far as I can make out, yet to be determined term. She suggests pro-freedom.

Some more thoughts on that Red C Poll… December 4, 2012

Posted by WorldbyStorm in Bioethics, Economy, Irish Politics, The Left.
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A few days have passed since the SBP Red C poll was released. And that offers time to work through the reasons that it may have seen such significant changes for at least one of the parties. The headline figures were as follows:

Fine Gael 28% (down 6%), Labour 14% (up 1%), Fianna Fail 20% (up 1%), Sinn Fein 17% (NC), Green Party 3% (up 1%), Independents, United Left Alliance and Others 18% (up 3%).

And while all others were broadly within their pre-existing levels of support, it is the FG figure which is most striking. In the space of a month it lost 6 per cent and in doing so dipped below 30 per cent for the first time in a Red C poll. As Pat Leahy put it:

A month ago Fine Gael was untouchable – miles ahead of everyone else on 34 per cent. Not today. Unbelievably, having dropped by six points to 28 per cent, Fine Gael now sees, approaching in the rear view mirror, its old enemy: Fianna Fáil.

That may be overstating it, and yet, and yet, both parties are now 8 per cent apart. That’s the thing with Irish politics, the closeness of FF and FG in terms of what they offer to voters is such that there is some (not a huge amount) interchangeability in that vote. Leahy argues that the death of Savita Halappanavar is a motive force in all this. I think it is to a considerable extent. But it’s very difficult not to believe that a broader dissatisfaction with FG over various issue, plus more immediately the travails of the Minister of Health, have also fed into this and that the abortion issue was in part a means by which this dissatisfaction could be activated.

Leahy makes a further crucial point:

It’s also clear from today’s numbers that the public is a good bit less conservative than Fine Gael on the abortion issue.

It’s arguable that the rather vociferous ‘pro-life’ FG TDs have done their party no good at all and it will be instructive if they moderate their tone in the next while. I put up an interview with Harvey Milk at the weekend where he noted that often a perception of greater strength of right wing attitudes than actually exists can prevent progressives from acting. In the case of abortion that seems to be the case. It is true that the death of Savita Halappanavar brought home the realities facing women in this state for many, but it is also difficult to believe that there had not been a slower shift in public opinion on the matter, and I think purely on an anecdotal level from my own perspective of hearing people on the matter – with all the necessary caveats – I would see that as being probably accurate.

Of course that doesn’t mean there’s a contradiction in all this. It could well be that despite all that FG remains a lot more conservative on the issue, that it is not tagging along after a perceived public opinion, but that its representatives are genuinely attached to much more conservative positions. It’s certainly telling to see names like Brian Hayes placed in the ‘pro-life’ camp.

The irony is that if the FG vote is a form of political collateral damage in respect of abortion legislation then it is truly a case of a party playing it safe and being undercut by changing public opinion – and a further irony, it is not economically linked.

That said on that latter matter Leahy makes a most interesting observation:

Public opinion has also shifted on the budget. Whereas previous surveys tended to show that the public was more in favour of public spending cuts than higher taxes, today’s poll shows that opposition to cuts in welfare payments, especially pensions, is shared by two-thirds of voters. However, a similar proportion (67 per cent) say that tax increases for higher earners – defined as those with over €100,000 household income – should be the first option for the government.
Voters favour further public sector pay cuts, rather than cuts to welfare and pensions, with a fifth of voters (21 per cent) saying it should be the first option, while over half (55 per cent) say it should be an option considered by the government. Just 20 per cent say the option of “higher taxes for all” should be considered, though a similar proportion say it should not be on the agenda at all.

One could dismiss all that as being a case that ‘anyone but us’ should be taxed or should have their wages cut, on the part of voters. But an appetite to increase higher taxes on those better off is at least moving in the right direction.
And he concludes by suggesting:

Overall, this poll shows not just political support but the political landscape moving away from the government parties. It’s not altogether clear what might replace this. But it does remind us of the underlying volatility that the economic crisis has wrought on Irish politics. The crisis has already changed our politics to an historic degree. That change is not necessarily at an end.

That’s the thing. As was put elsewhere, FF is positioning itself to the right of SF and to the left, marginally, of the Government. That may reap dividends, and already it is six points above where it was in similar polling half a year ago. All FF wants is to recover lost ground, as much and as fast as it can. So it will do literally anything to achieve that end. No more the chatter about FF becoming a niche right wing party that we heard in the aftermath of the election. Their ambitions are much much bigger than to be a PD redux. But it could be that their rather minor gain is because others have made the running in this – indeed a not dissimilar dynamic could explain why SF haven’t improved upon their position, given the very public and rather unusual – for them – apostasy from the party line on this particular issue.
Look at the Independents and Others who are up to 18 per cent. What remains striking is how the supposedly impotent and irrelevant Independents and Others continue to command a vast share of the vote. Yet if anything the recent events have shown how even given near non-existent political power they retain an ability to shape the discourse and in ways that are both positive for themselves and immensely damaging to their rivals. Again it seems reasonable to propose that this is a function of the most recent events, and particularly the high profile of Clare Daly, and Joan Collins and Mick Wallace in matters (a lot is made of the fact that those involved mention each others names a lot, but it would seem to be an approach that is not without merit if one wishes to solidify the Independent and Others vote share).
In a way what all this reminds me of is the way that when the opportunity arrived for voters to turn their backs on the Fianna Fáil and the Green Party during the last government they did so and in droves. It’s as if there is a need for ‘permission’ in these matters, and once it is given, or rather taken, then that’s that. It’s not, as Leahy notes, that ‘these positions are set in stone’. FG could recover though I hesitate to use the word ‘easily’. But with so much bad news still in train… it may be that this is a key moment in the electoral cycle.
And a Budget tomorrow!

A ‘special level of support’… April 25, 2012

Posted by WorldbyStorm in Bioethics, Uncategorized.
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In relation to the issue of women who had pregnancies where there were fatal foetal abnormalities it is interesting to note the proposed solution for that issue from one quarter, that being,

…the establishment of perinatal hospices so women could receive a “special level of support”.

Without doubting for a moment that such a facility would be of considerable service to a proportion of those in that situation (and the NYT in this article notes that many of those within these hospices ‘seem free of ideology’ in any respect) for others the prospect of continuing through a pregnancy in this context in such institutions certainly doesn’t appear to come close to addressing their needs.

There’s also the thought that these institutions, in an Irish context have an odd echoes of a harsher and even more profoundly paternalistic time in this society.

Surrogacy… April 10, 2012

Posted by WorldbyStorm in Bioethics, Social Policy.
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Breda O’Brien had an article in the Irish Times a while back about surrogate mothers.

This can seem a particularly attractive option, where the couple’s own genetic material is being used. The child will grow up and be part of a biologically related network of relatives.

We see in media reports delighted parents talking in emotional terms about the precious gift of life which a generous woman has given them.
Then there are the heart-rending stories of “stateless” children, whose genetic parents have no rights. For what it’s worth, I would be in favour of regularising the situation of these children as swiftly as possible. They are as precious as any other children and deserve their basic rights to an identity, a family and a nationality.

But…

However, I would then ban surrogacy, as they have done in other European states such as Austria, Germany and France. The European Court of Human Rights recently upheld the Austrian ban on surrogacy. The Austrian argument is that “splitting” motherhood between a biological and gestational mother is a very bad idea for children, and even worse when another party or two is involved, as in the case of donor eggs and sperm.

It’s interesting to read some of her reasoning as to why she’d ban it.

Rebecca Haimowitz and Vaishali Sinha made a documentary called Made in India about two middle-class Americans contracting a woman, Aasyia, in Mumbai, to carry their biological child. Aasyia is shown wearing a hijab in her one-room home that she shares with her husband and three beautiful children. The hijab is not for religious reasons, but to prevent her being identified by her neighbours. When she first heard about surrogacy, she laughed, because she did not know pregnancy was possible without “a relationship with a man”.

Then, this quick-witted, resourceful woman, who admits she cannot read or write, says while her sons can fend for themselves, the $2,000 she could earn through surrogacy will help her provide for her daughter.

But it is worth asking: can an illiterate woman who didn’t even know surrogacy was possible and is desperate to help her children truly give informed consent?

These are good questions. But interestingly, it’s not the exploitation issue that trumps it for O’Brien. She writes…

What if the woman is not exploited, but properly remunerated? After all, $2,000 for 24 hours a day for nine months, and then birth, followed by empty arms, amounts to slave labour rates. I’m not sure how you remunerate a woman for having a child grow under her heart for nine months, all the time refusing to allow herself to get attached to her or him. But if you make a payment like €25,000, at least you are closer to the truth of acknowledging this is a commercial transaction.

I’d be very dubious about surrogacy in potentially or actually exploitative contexts (and more here from Feminist Ire on the issue ). But that’s not the entirety of it – whatever about the ‘grow under her heart’ line Because it’s not simply about being a commercial transaction, not simply about ‘exploitation’ potential or actual.

There’s a fascinating anecdote in Liza Mundy’s Everything Conceivable, one of the most interesting books I read in the last year, about a woman named Ann Nelson in Michigan who was a graduate of Michigan State where she ‘took classes in bioethics and wrote a thesis on reproduction that covered everything from abortion to breast-feeding. Her research included surrogacy…she was intrigued rather than appalled. “I decided then that I wanted to do it. Because I could. That’s not something most surrogates will telly. most surrogates will tell you they wanted to help somebody. I wanted to do it because I knew I could do it.”

And Mundy continues:

For Ann Nelson, who is also an environmental activist and a counsellor of pregnant teens, surrogacy was part of what she calls “a grassroots thing. I thought, ‘I could help these poor people”.

She eventually became surrogate on a number of occasions for various gay couples. The book considers in detail her surrogacy for a gay couple, Doug and Eric, which raises the central point:

‘Even now Doug and Eric cannot grasp surrogacy and why women do it. It’s easy, they think, to understand why somebody, anybody, would want children. What is harder to get one’s mind around is why someone would want to have children for someone else. “It’s really hard to fully appreciate,” says Doug. “We are so incredibly grateful. And yet we really don’t understand it.”

Nelson argues that ‘the reproductive rights umbrella should include gay men, and her own reproductive rights should include the right to help gay men [and presumably all others as well - wbs] build the families they long for.

Perhaps that example, having a gay couple involved in the process, is a bit outré for O’Brien. So what then of the far from infrequent examples where siblings or other relatives have been surrogates? In that instance the charge of exploitation begins to seem very thin indeed.

The problem with the O’Brien approach is that rather than coming out and saying clearly that she is against surrogacy, period and explaining why, instead she brings in all manner of extraneous issues. Few would stand over any exploitative practices, such as arguably those we see in India and other states. But the point is that it is entirely possible to design programmes that are not exploitative, or where there is a minimum of such exploitation. And to point to the worst excesses is to ignore more central aspects of the issue. There may indeed be good reasons why surrogacy is far from optimal and there may not, although it may also be moot given the fact that in the United States it is now far from unusual, but these are not they and as part of an addition to a general discourse on such matters they evade rather than focus upon what it means now and implies as regards the approaches towards such matters in this state.

There’s more though. In 2005 the Commission on Assisted Human Reproduction issued a report. The Commission was an attempt to find a way through the thicket of issues surrounding AHR. And as the foreword to the Report notes:

The Commission on Assisted Human Reproduction was set up to report on possible approaches to the
regulation of all aspects of assisted human reproduction and the social, ethical and legal factors to be taken into
account in determining public policy, in this area. The phrase assisted human reproduction was
understood by the Commission to refer to any procedure that involves the handling of gametes or embryos.
Where feasible the Commission has avoided the excessive use of medical and scientific language in the report.

Those involved?

Chairperson:
Professor Dervilla Donnelly
Emeritus Professor of Organic Chemistry, University College Dublin.
Chairman, Council of Dublin Institute for Advanced Studies.
Dr. Carole Barry-Kinsella
Consultant Obstetrician Gynaecologist, Rotunda Hospital, Dublin.
Ms. Helen Browne
Co-founder & Chairperson of the National Infertility Support & Information Group (NISIG).
Dr. Alpha Connelly
Chief Executive of the Human Rights Commission – June 2002, formerly Legal Adviser in the Department
of Foreign Affairs.
Ms. Mary Cooke
Advisory Counsel, Office of the Attorney General (resigned 2002).
Professor Thomas G. Cotter
Department of Biochemistry, University College Cork.
Ms. Nora Geary
Registered General Nurse, Unified Maternity Services, Cork University Hospital Group.
Professor Andrew J. Green
Director, National Centre for Medical Genetics, Crumlin, Dublin.
Professor of Medical Genetics, University College Dublin.
Ms. Caroline M. Harrison
Psychotherapist, Human Assisted Reproduction Ireland (HARI), Rotunda Hospital, Dublin.
Dr. Nуirнn Hayes
Head of School of Social Sciences and Legal Studies, Dublin Institute of Technology.
Ms. Benny Hennelly
Midwife, HARI Unit, Rotunda Hospital, Dublin.
Ms. Dora Hennessy
Principal Officer, Department of Health and Children (resigned 2001).
Dr. Declan Keane
Master, National Maternity Hospital, Dublin (resigned 2001).
Ms. Geraldine Luddy
Director, Women’s Health Council.
Professor Marina Lynch
Department of Physiology, Trinity College Dublin.
Dr. Deirdre Madden
Lecturer, The Law Department, University College Cork.
Dr. Miriam McCarthy
Senior Medical Officer, Department of Health, Social Services and Public Safety, Northern Ireland (replaced
Dr. Glenda Mock).
Dr. Paul McCarthy
Child Psychiatrist, formerly of St. James Hospital, Dublin.
Dr. Glenda Mock
Senior Medical Officer, Department of Health, Social Services and Public Safety, Northern Ireland (resigned
2000).
Mr. Brian Mullen
Principal Officer, Department of Health and Children, Dublin (replaced Ms. Dora Hennessy).
Dr. Aonghus Nolan
Embryologist, Fertility Unit, University College Hospital Galway.
Ms. Christine O’Rourke
Advisory Counsel, Office of the Attorney General, Dublin (replaced Ms Mary Cooke).
Professor Anthony Ryan
Consultant Neonatologist/Paediatrician, Cork University Hospital.
Professor Gerry Whyte
Associate Professor, The Law School, Trinity College Dublin.
Dr. Mary Wingfield
Consultant Obstetrician Gynaecologist, National Maternity Hospital, Dublin. Representative of Institute
of Obstetricians and Gynaecologists (replaced Dr. Declan Keane).

And conclusions?

Surrogacy arrangements can take place using IVF or AI techniques, but may also be carried out without any
medical intervention. Where surrogacy is carried out privately and without medical intervention, the
arrangement would be impossible to regulate.
The arguments considered during the Commission’s discussions include the following:
ARGUMENTS IN FAVOUR OF SURROGACY
• Given the shortage of children available for adoption, surrogacy might be the only option for some
people to have a family, especially in cases of non-traditional families where adoption poses particular
problems.
• The right to procreate should extend to surrogacy arrangements made by fully autonomous adults,
once no harm to children is expected as a result.
• Surrogacy may be understood as an expression of altruism.
• The use of the human body for surrogacy is ethically indistinguishable from other accepted practices
that separate genetic, gestational and social parenting, such as donor insemination, adoption and wet
nursing. It is also indistinguishable from other practices whereby the human body may be seen as
being utilised for profit, such as professional athletics and modelling.
29The Commission recommends that in general, donors should not be permitted to attach
conditions to donation, except in situations of intra-familial donation or the use of
donated gametes/embryos for research.
• Although some people may find the practice of surrogacy inherently objectionable, the State should
not enforce one set of values against those who do not share those values and, in the absence of
demonstrable harm to children or others involved in surrogacy, should remain neutral.
• Although much research needs to be done on the follow-up of children born through surrogacy, the
most recent research carried out (on very young children) indicates that commissioning parents are
more attentive than average to children and the well-being indicators for the children are very positive
at this stage.
ARGUMENTS AGAINST SURROGACY
• Surrogacy represents the incursion of market values into gestation and traditional values of
reproduction.
• Commercial surrogacy involves the use of contractual models whereby those who agree to become
surrogate mothers are vulnerable to exploitation. Respect and consideration for women demands that
this potential for exploitation be prohibited by the prevention of surrogacy contracts.
• The commercialisation of gestation places a monetary value on children which conflicts with their
fundamental rights to be loved unconditionally as individuals and not as commodities.
• Surrogacy is unnatural because it separates the genetic, gestational and social roles of motherhood.
Society should not interfere with the laws of nature by adjusting the natural or standard physiology of
reproduction.
• Respect for human beings demands that no person should ever be used as a means to an end. The
involvement of a third party as gestator for the child treats her as an object by which the achievement
of the birth of a child can be attained. The commissioning party hires her in order to satisfy their own
desires, rather than to give life to a child.
• A woman cannot possibly know before becoming pregnant and carrying the child for the duration of
the pregnancy how she will feel on having to relinquish that child at birth. Her perceptions about
attachment to the child may be very different at the time of her agreement to become a surrogate
mother from when she gives birth and it is unreasonable to expect her to contract out of her right to
retain custody of the child.
The Commission considered how best to address the ethical and legal concerns in relation to surrogacy and
whether it was preferable to regulate or prohibit surrogacy.
The majority of members were in favour of regulating surrogacy, and all members were strongly of the view
that commercialisation of the practice should not be permitted by the regulatory authority.
One member was strongly opposed to regulation and took the view that surrogacy ought to be prohibited. Such
opposition was based on the opinion that surrogacy inherently entails risks of exploitation of women and
commodification of children. On this view, public policy dictates taking a strong stance against such
arrangements and should prohibit commercial agencies from seeking to make a profit from surrogacy. It was
also argued that the recognition by the State of the legitimacy of surrogacy, even in tightly regulated
circumstances, would give rise to a growth of such arrangements on a commercialised basis.

It would have been useful for O’Brien to reference the Commission, which is – of course – even though it has not been acted upon in subsequent years, is the closest we have come to a democratically legitimised effort to engage with this area. It might have been particularly useful for her to note that the outcome of the deliberations of the Commission was that surrogacy should be legal in the Republic, albeit it should not be commodified. There was only one dissenting member.

But to not do so suggests she is unwilling to engage with the issue in a manner which does it full justice. There’s no one, I imagine, who thinks that these issues are closed to discussion. Even if the processes are much more straightforward than is often pretended (surrogacy after all being merely an extension of already tried and tested IVF techniques) for those caught up in them they present genuine challenges. But pointing to extremes as if they represent the totality is untenable.

Alive! March 15, 2012

Posted by WorldbyStorm in Bioethics, Social Policy.
18 comments

Alive! was dropped through my letterbox recently.

And as ever it’s a fascinating read. I’ve got to be honest, it doesn’t irritate me as much as some. In part because what some people believe doesn’t exercise me as long as it doesn’t impact negatively on me. Of course, that only takes one so far living in this state, but it does make for a somewhat more pleasurable reading experience.

Still no end of material to engage with. For example, Fr. Owen Gorman has a nice article about ‘helping childless couples’ and IVF. I’m always interested in this area, indeed I mentioned the impression a book I read last year about ART and related issues in comments here.

Fr. Owen has bad news though. Having run through the history of IVF from the first ‘test tube’ baby Louise Brown onwards he notes that ‘although the Church rejoices at the birth of every new child and welcomes him or her to the human family, it does not consider IVF morally good’. And worse… ‘many Catholics are not aware of the ways in which IVF seriously transgresses the moral law’.

He continues:

IVF presents us with a mixture of moral violations. First of all, the male semen used to fertilisethe female eggs is usually acquired through masturbation, a violation of sexual ethics.

Okay, way to go making new friends and influencing real living breathing human people…

But he goes on and notes that mixing sperm and eggs ‘in a glass petri dish to produce several embryonic human beings…violates the basic right of every human being to be conceived through the personal, one-flesh communion of their parents’.

And he concludes…

But by far the most serious violation of the moral law concerns what happens to the human embryos that are not implanted in the womb. They are discarded, frozen or handed over for scientific research. Thus a culture of death involving the killing and manipulation of human life is intrinsically part of IVF.

Again, none of this particularly irritates me. I’m a bit dubious about his line about the issue of embryos not implanted in the womb. As IVF technologies have improved the numbers produced have decreased. Moreover he should be aware that realistically – and dependent upon age and other criteria, the numbers of eggs produced from such procedures tend to be on the low side and if there’s an excess that’s unusual enough. Then there’s the issue about how fertilised eggs ‘naturally’ conceived don’t implant either. They too are ‘discarded’.

All this is, in fairness, his belief, and who am I to argue with that?

But the following does irritate me, at least a little bit.

He presents the following alternative.

…morally licit treatments that married couples can use in order to help them conceive a child. One such procedure is NAPRO.

NAPRO Is essentially the Catholic Church’s line on IVF made manifest. It isn’t IVF, but instead supposedly ‘natural’ investigations and processes to encourage fertility. Or as its proponents say themselves:

Natural procreative (NaPro) technology. NaPro technology was developed by obstetrician and gynecologist Thomas W. Hilgers in Omaha, Neb. Central to the technique is educating women and couples how to precisely monitor and chart female bodily “markers” that indicate fertility and fertility problems. This allows the NaPro technology practitioner to zero in on abnormal menstrual bleeding patterns, poor cervical mucus flow and subtle hormonal deficiencies that are often not detected by routine gynecological evaluation. Once the biological problem is identified, a precisely targeted solution can be undertaken.

This solution doesn’t involve the techniques that IVF does such as developing embryos and so on. Anyhow, Fr. Gorman argues that ‘it has an overall success rate of about 40%’.

This is very problematic. As a piece in the Washington Post noted in 2006…

Experts also question how “natural” … techniques are if they employ hormonal supplementation, and they criticize him for not publishing studies in medical journals so … methods can be evaluated independently.

Indeed the deficit of clear information about NAPRO is deeply troubling. One clear issue in the studies actually released by proponents of NAPRO is that they do not break down age, and other cohort information. This means that a clear means of assessing success rates or otherwise and contextualising them with IVF clinics is impossible.

And in both the UK, the US and elsewhere best practice is for IVF clinics to break down outcomes according to age of the woman. Indeed the US Centers for Disease Control and Prevention carries that data for all and any to see.

This isn’t a mere detail. For those facing infertility time is often, though not always, of the essence. But so is information. If NAPRO is treating cases of younger individuals with issues more amenable to less complex processes then it is possible that that skews their statistics. But without the hard data on those statistics other than broad general percentages one simply will not know. There are broader issues. Infertility is a symptom of many issues, many more than listed in the quote above. And NAPRO, per definition due to its aversion to various IVF techniques is simply unable to address that fact.

None of which is to say that NAPRO won’t work for some. It will for those in certain cohorts and there’s a clinic in Galway that offers it and as long as the information on what it can and cannot do is fully transparent that’s fine. But to suggest that it is a replacement for IVF is a stretch.

IVF and bioethics… November 24, 2011

Posted by WorldbyStorm in Bioethics, Science, Social Policy.
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Interesting editorial in the Irish Times about IVF this week. That said, there are a couple of assumptions I’d be a little hesitant about…

There’s little to quibble with the following:

THE FIRST live birth following in-vitro fertilisation (IVF) just over 30 years ago marked the start of a reproductive revolution. It involved fertilising a woman’s eggs with sperm, before transferring them back into the uterus a few days later. Today, assisted human reproduction in Ireland is a booming industry.

Though I’m never keen on the latter way of formulating it – though as I’ve noted previously there have been iniquities in relation to tax reliefs for people undergoing IVF [as with many medical procedures] where relief is at higher or lower rates, or at least was until recently, and therefore made what are by any measure expensive procedures prohibitively expensive for many – not least because IVF is not a one-shot event but something that is more akin to a process which may require multiple tries and even then with no guarantee of success.

Couples are increasingly choosing to have children later in life, which increases the likelihood of fertility problems. Restrictions on international adoption mean that many would-be parents are exploring other ways of having a child.

I wonder if that’s the dynamic at play? I suspect many go from IVF to adoption when the former proves unsuccessful. In other words IVF is now overwhelmingly likely to be the first port of call. Indeed it makes sense, infertility is in essence a medical problem and embarking on IVF comes on foot of referrals by family doctors when people discover that despite their own efforts pregnancies aren’t taking place.
In any event we’re now at a place where…

…up to 3,000 children are born here each year thanks to IVF and other high-tech interventions.

Actually some of them are probably quite low tech. IUI is fairly straightforward and more on this low-tech aspect in a moment. But note the following:

Yet there are no laws to regulate the industry. Ireland is almost alone in Europe in failing to provide any legislation or meaningful regulation. This gap is leaving many families, children and clinicians caught in a complicated web of legal and ethical uncertainty. As documented in Carl O’Brien’s 21st Century Baby series in this newspaper, the legislative gaps mean we have stateless children born by surrogacy with no legal parents; hundreds of children born as a result of anonymous donor sperm or eggs who will never know their genetic parents; parents who are forced to go abroad for donor assistance due to the State’s failure to provide any certainty for potential donors here.

I’m not entirely sure if that’s correct either. The absence of a framework doesn’t necessarily mean that there are impediments in all cases. Take donor eggs. It is possible to conceive using donor eggs in this state, but the supply is limited and often restricted to close friends or family assisting those seeking donor eggs. What is more likely to happen is that those who go down that path go to Europe [sometimes the Irish clinics will have programmes that facilitate precisely that] and even in that instance the issue of genetic parentage is open to question. For example a number of European states which allow donor eggs and sperm only do so under strict anonymity, so even if legislation changes here that will have no impact at all on that particular facet of the issue.

Indeed it is the this transnational element that perhaps points up how everything has changed and changed utterly. A world of Ryanair flights and much less expensive procedures than even a decade ago makes national decisions or approaches on this somewhat moot.

Which of course is not to say there should be no national policy frameworks. As the IT notes:

It is now over a decade since the government established the Commission on Assisted Human Reproduction to advise on how the area could be regulated. Six years ago, the group issued a series of considered recommendations. The government of the day pledged to introduce legislation as a priority issue. But there is still no sign of these proposed regulations.

I felt at the time, and still do, that one of the reasons for the non-appearance of those regulations was that it was easier for an intrinsically socially conservative party [in the main] like Fianna Fáil to duck the issue rather than confronting it head on. Not least because IVF and reproductive technologies not merely raise the ire of traditionalist religious of various stripes but also some aspects of conflict with some progressives. That doesn’t surprise me, this area is fraught with contradiction, paradox and profoundly difficult questions for many.

I mentioned earlier this year in comments to this post about Everything Conceivable: How Assisted Reproduction is Changing Men, Women and the World – by Liza Mundy which I found a fascinating and in parts deeply thought-provoking text about where reproductive technologies are leading us us. I probably take what might be regarded as a libertarian view on these issues not least because I suspect that these technologies, as the Irish Times itself notes, are already fundamentally reworking and reshaping our societies in small but significant ways, but also because I don’t believe they can be rolled back. What’s most amazing is that far from the image of these as being near-NASA like technologies of incredible fragility and contingency the reality is that they’re sturdy, easy to replicate and, as noted by Mundy in her research, can be practically established out of any shopping mall were the need to arise [indeed in the US which is almost entirely unregulated in this area that’s often precisely where they do operate out of]. Indeed much of the ‘aura’ of immanence I suspect comes from the perception – not entirely incorrectly either – that this is dealing with the fundamentals of life rather than the techniques themselves which in some respects are remarkably mundane from ground level.

Not that I entirely agree with the following either.

In addition, scientific advances are allowing forms of family life that were never possible before: single women or men who have decided, in the absence of a partner, to have a child, or gay couples who are co-parenting. The lack of a debate surrounding support for these family units means we have yet to face up to what, in time, may become one of the most socially influential technologies of the 21st century.

While obviously agreeing with the latter contention I’m dubious about the former. A small statistic perhaps brings home a reality that was often not faced up to …

Up to one in 10 men is not the true father of the children they think are theirs, according to new research by Biosciences, one of the leading DNA testing organisations.

What does that prove? That human relationships are complex affairs and that mon “conventional” family building has been going on for decades, centuries, and more power to people’s elbows too in that regard. And while the advent of these technologies has obviously assisted that, and perhaps may have the benefit of finally seeing them regarded as “conventional”, it’s only adding to something that was in play whether societies were willing to acknowledge that or not. Indeed as with too much there’s far too much of a tendency to see the past in a remarkably undifferentiated and un-nuanced fashion in these matters. And children and parents manage, in general to muddle along.

None of which is to dispute the conclusion of the IT editorial.

We urgently need our legislators to stop burying their heads in the sand and face up to how society is changing. Its failure to do so means that legal and ethical uncertainty will continue to be a gnawing source of stress for parents, and vulnerable children will be caught up in the fallout.

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