AMA Journal of Ethics^®

On a summer night in 1978, as the hour approached midnight, Dr. Patrick Steptoe prepared himself for surgery [1]. A veteran obstetrician and gynecologist nearing retirement, Dr. Steptoe had delivered many babies by caesarean section, and he performed the surgery flawlessly [1]. At 11:47 pm, Louise Joy Brown came into the world, perfect and exquisite and vulnerable in that way only babies can be, though Louise Joy Brown was no ordinary baby [1]. To her parents, she was an unexpected and yearned-for gift after almost 10 years of trying to conceive; to Dr. Steptoe and his colleague, Robert Edwards, she was the culmination of countless years of research; and, to the world, she was a mixture of scientific triumph and medical marvel. She was the first so called “test tube baby,” or, in the correct scientific parlance, the first baby born following in vitro fertilization (IVF), which entails extracting eggs from a woman using a needle, fertilizing one or more with sperm, and then inserting one or more of the embryos into her uterus with the hopes that one implants. This year, a pregnant Louise celebrated her thirty-fifth birthday, with her husband and their first child [2].

In those 35 years since Louise’s birth, the field of assisted reproductive technology (ART) has flourished. What was on that July night a scientific breakthrough has become commonplace. Couples who are carriers for devastating genetic conditions they don’t want to pass on, gay and lesbian couples, women with anatomic abnormalities that prevent them from conceiving, men with abnormalities in their sperm, and countless others have found ART to be a kind of savior science, a way to have children when nature has denied them that option. ART has helped millions of people desperate for babies, like the Browns, to conceive, and, to date, more than 5 million babies have been born with the help of assisted reproductive technology [3].

But ART is not without controversy, as is generally the case in any rapidly expanding field. As the technology has powered ahead, questions about its ethical and moral implications, along with the appropriate regulation to protect the rights of all parties involved, remain unresolved, and its high cost and, hence, limited availability raise questions of distributive justice.

In many ways, ART highlights ethical dilemmas that exist, in more subtle forms, throughout all of medicine. What does a doctor do when he or she questions the decisions a patient is making? Can a doctor’s personal values ever trump those of the patient? When two of the physician’s patients have different interests in the same outcome (as can happen in surrogacy arrangements, for example), where do the physician’s loyalties lie? What obligations do physicians have to an unborn fetus and to a future child?

ART also raises questions about how medical technology should be regulated. Should regulation be in the hands of the government or in the hands of ART practitioners themselves? Should there be recommendations or laws? How much regulation is too much, and how much is too little? And are there limits on how far this technology should be allowed to progress?

So too does ART raise questions that are uniquely related to reproductive technology itself. What compensation should there be for egg donors? Is it ethical for fertility clinics to offer risk-sharing programs to their patients? What social impact, if any, does ART have on the children that result from it?

Ultimately, at the heart of the ethical dilemmas surrounding ART is our understanding of reproductive choice. How do we define this term, what do we value most about it, and how do we protect it?

Through a series of articles written by physicians, scientists, lawyers, public health experts, and students and a podcast with Thomas Price, MD, this issue of Virtual Mentor explores these questions thoughtfully. They are difficult ones, with no absolute answers and, sometimes, no obvious practical solutions. But as new techniques develop and use of ART grows, as it undoubtedly will, we are obliged to consider what that growth means, what aspects of procreation we as a society value most, and, perhaps most importantly, how we can best serve the interests of all future parents and their future children. This issue honors that obligation.