European Journal of Obstetrics & Gynecology and

Reproductive Biology 90 (2000) 171–180 www.elsevier.com / locate / ejogrb

Review

Ethics and assisted reproduction

Sozos J. Fasouliotis M.D., Joseph G. Schenker M.D.*

Department of Obstetrics and Gynecology, Hebrew University, Hadassah Medical Center, P.O. Box 12000, Jerusalem, 91120, Israel

Abstract

In vitro fertilization and assisted reproductive technology have made great progress during the last 20 years. Genetic material donation,
human embryo cryopreservation, selective embryo reduction, preimplantation genetic diagnosis and surrogacy are currently practiced in
many countries. On the other hand, embryo research is practiced only in a small number of nations, whereas human cloning has thus far
been universally condemned. The rapid evolution and progress of all these techniques of assisted reproduction has revealed certain ethical
issues that have to be addressed.  2000 Elsevier Science Ireland Ltd. All rights reserved.

Keywords: Assisted reproductive technologies; Ethics

1. Introduction unsatisfactory, to have taken part in the efforts to check the

The medical profession has a history of ethical behavior
that goes back at least to the year 2000 BC. In the Codex
Laws by Hammurabi, various legal systems have incorpo-
rated, to some extent, regulation of physicians. Also, in the
ancient Hebrew writing, the Talmud, there are passages
about the high moral standards and responsibilities ex-
pected of physicians and instructions about the relations
between the physician and the patient, as well as specific
ethical dilemmas. However, it is the Hippocratic Oath that
set the early concern of the medical profession for regulat-
ing itself by laying down basic standards of conduct
between the physician and the patient [1].
Hippocrates, the Father of Scientific Medicine, was born
in the island of Cos between 470 and 460 BC, and
belonged to a family that claimed descent from the
mythical Asclepios, son of Apollo. He lived in Greece
during the ‘Golden Century’, when the Art and the
Intellectuals searched for the first time the Truth, building
in this way the basis of the contemporary scientific
thought, perception and civilization. There was already a
long medical tradition in Greece before his day, and this,
he is supposed to have inherited chiefly through his
predecessor Herodicus; and he enlarged his education by
extensive travel. He is said, though the evidence is
*Corresponding author.
0301-2115 / 00 / $ – see front matter  2000 Elsevier Science Ireland Ltd. All rights reserved.
PII: S0301-2115( 00 )00271-2
great plague which devastated Athens at the beginning of
the Peloponnesian war. He died at Larissa between 380
and 360 BC.
Hippocrates’ work is a breakthrough in the history of
medicine, which before him was found at the everyday
stage of theocrat-priestly Medicine. In that time,
philosophers such as Empedocles and Democritus were
proclaiming each his own explanation of the universe and
the nature of man. Hippocrates defied what he called the
‘unproven hypotheses’ of the philosophers, and declared
that only the study and observation of nature and of man
would point the way to truth. He has traced the new road
of the scientific medicine, as the word ‘science’ is meant
nowadays. He studied man in health and in disease,
making of medicine a science and an art. But he saw in
man something beyond any discovery that can be made
elsewhere in nature, and thus added a moral code, a
religion of medical service [2].
Hippocrates Oath consists of the oldest code of medical
ethics, and has formed the basis for the Vowel of graduates
of medical schools and the health professions all over the
world. In the oath that he required of his disciples there are
such phrases as this: ‘I will use treatment to help the sick
according to my ability and judgement, but never with a
view to injury or wrongdoing . . . I will keep pure and holy
both my life and my art’. Thus, he recognized the moral
and the spiritual as well as the physical and the material. In
172 S. J. Fasouliotis, J.G. Schenker / European Journal of Obstetrics & Gynecology and Reproductive Biology 90 (2000) 171 – 180
addition, this interesting document shows that in his time
physicians were already organized into a corporation or
guild, with regulations for the training of disciples, and
with a professional ideal which, with slight exceptions, can
hardly yet be regarded as out of date [3].
While his teaching is based on ethical values, his
medicine is characterized by a genius in the perception and
scientific approach in the medical action. He enters the
methods of experimental research, classifies his observa-
tions and fights against superstitions and introduces
philosophy in his teaching. He believes that experience and
mind, with speech, are the criteria of the knowledge.
According to Hippocrates, the diseases are not due to the
‘wrath of God’, but to natural causes which bring about
disturbances in the function of the organism. The patient is
confronted as a psychosomatic entity and the medicine is
the adaptation of the therapy in the concrete patient. Also,
in the works of Hippocrates we find systematized, the
examination methods, the review, the audition, and the
clinical description of the pathological situations. Hippoc-
rates’ regulations are rephrased in the book ‘Aphorismoi’
which for 2000 years (until the 18th century) was consid-
ered to be the classical text of medicine. Although little is
known about the life of Hippocrates, it is certain he has
influenced many lives, and still does today [4].
Based on Hippocrates’ Principles, ethics has become an
important value of all medical search and treatment and
during generations, the physician’s commitment to the
patient has always remained the ethical ideal by which the
physicians and the public judged medical care. This
indicates that medical ethics has solely dealt with the
physician–patient relationship. Only in the last two de-
cades have ethical issues in medicine exploded into the
public consciousness at an exponential rate. This is due to
the following facts: scientific advances and their communi-
cation to the public, new technological developments that
can be applied in medicines’ life-saving procedures, and
increased access to the existing medical services, mainly in
the developed countries.
The public is at present aggressively interested in how
and to whom health care is delivered. Society’s concern for
ethical issues of medical practice has led to a growing need
of the medical profession to be fully aware of the public
view, not only on individual patient–physician relation-
ships, but also on how the new developments in medicine
affect the issue of human rights, social structure, and
health policy.
Developments in reproductive medicine over the last 20
years have created unexpected unprecedented public inter-
est in certain aspects of human reproduction together with
demands not encountered previously and their attendant
moral dilemmas.
One of the greatest medical advances achieved in the
20th century was the introduction and development of the
assisted reproductive technologies (ART). Many years of
effort were finally rewarded by the announcement in 1978
by Edwards and Steptoe of the birth of Louise Brown, the
first child born after in vitro fertilization (IVF) treatment
[5]. Following this breakthrough, IVF therapy rapidly
spread throughout the world, and currently is provided in
the majority of nations.
However, after the initial enthusiasm many ethical, legal
and social issues related to the application of these
procedures began to evolve, which led to serious discus-
sions and often disagreements among the involved physi-
cians, public and the state itself [6]. Also, the various
religions, which in many parts of the world still substan-
tially influence reproductive attitudes, did not remain
uninvolved [7]. The main issues which raised ethical
dilemmas following developments of ART are the moral
status of the embryo; the involvement of a third party in
the reproductive process by genetic material donation; the
practice of surrogacy; human embryo cryopreservation;
pre-embryo research; gamete manipulation, etc.
From the beginning of this new therapeutic approach,
scientists have emphasized the importance of resolving the
ethical issues involved [8]. However, it is very difficult to
find solutions to the ethical problems in reproductive
technologies that are acceptable in pluralistic society, and
it is even more problematic to reach consensus on univer-
sal policy. Therefore, each society and nation should have
some mechanism for ethical review when modern treat-
ment of infertility is applied [9].
Approaching the end of the 20th century, the assisted
reproductive technologies continued to pose an increasing
source of ethical dilemmas for physicians, scientists,
legislators, religious authorities and the general public to
deal with. The purpose of this study is to review the ethical
aspects of some selected general topics in ART.
2. Genetic material donation
Genetic material donation has become an integral part of
the management of infertility [10]. However, it raises a
multitude of ethical issues, since it involves several parties
with separate interests; the donors, the recipients and the
offspring [11].
The privacy versus disclosure debate is one of the main
issues of controversy in assisted reproduction with donor
gametes, centered on the traditional anonymity, if not
secrecy, of the procedure [12]. Most ethical committees
have recommended that the anonymity of the donors be
maintained. The children born following genetic material
donation may have a social stigma and suffer from
psychological and social trauma. In the field of assisted
reproduction, the absence of genetic link between the child
and a parent or both parents may endanger the relationship
between the non-genetic parent and the child [13]. Family
relationships, in which the truth is withheld from the child
(either in cases of donor insemination or egg donation),
may be undermined, contributing to the possible appear-
ance of identity confusion in these children [14]. This is in
itself a reason for maintaining secrecy. Research on
 S. J. Fasouliotis, J.G. Schenker / European Journal of Obstetrics & Gynecology and Reproductive Biology 90 (2000) 171 – 180
children conceived by gamete donation shows not only that
these children are functioning well, but also that they have
better relationships with their parents than children who
have been naturally conceived [15]. This suggests that a
strong desire for parenthood seems to be more important
than genetic relatedness for fostering positive family
relationships, and that the conception by gamete donation
does not appear to have an adverse effect on the socio-
emotional development of the child.
In addition, the donors must be protected from legal
liabilities of child maintenance and inheritance rights [16].
In the case of a defective child born resulting from the
donation, the donors may be charged with negligence or
failure to provide a full medical or family history. Access
to identifying information could lead to unwanted invasion
of the donors’ life by the offspring seeking their genetic
parents [17].
However, there are those who argue against donor
anonymity [18]. These claim that the truth should always
be told, or that each individual has the right to know its
biological origin. A child resulting from gamete donation
may, in the event of illness, be harmed by not knowing his
genetic constitution or family medical history of the
donors. Furthermore, the child may accidentally discover
data regarding his or her conception, through blood testing
or tissue typing and eventual harm may ensue. It is
therefore essential to disclose to the involved parties the
possible repercussions of the procedure. Recipients must
be informed of the medical and psychological screening
procedures which have been performed, the extent of their
anonymity and any legal uncertainties concerning their
parentage or future involvement by the donating indi-
vidual. Each IVF program should make a policy con-
cerning the degree of involvement of the donors in the
allocation of the gametes, and this should be made known
to all involved parties [19].
Another issue involves the payment for genetic material
donation. Most international ethical committees’ state-
ments stressed that gamete and pre-embryo donors should
not be reimbursed for their donation [20]. However, in
some countries sperm donation and often oocyte donation
are paid for. Some regulations found a solution to this
ethical problem by giving compensation for time and
expenses associated with the donation, namely assisted
reproduction [21].
Other basic issues involve genetic material donation to
single or lesbian mothers and the application of a limit to
the age of the recipients. These issues will be discussed
furthermore in the article.
3. Embryo research
There are potential interventions that may be performed
in the pre-embryo stage that may lead to improvement of
the clinical results of ART, as well as, to prevent the birth
of offspring with genetic aberrations. Currently, the fol-
173
lowing therapeutic measures can be potentially applied to
the pre-embryo: improvement of culture conditions, pre-
embryo cryopreservation, assisted hatching, genetic diag-
nosis and gene therapy. In order to discuss the parents’
rights and duties in applying therapeutic measures to the
pre-embryo, it is essential to clarify the ethical and legal
dilemmas concerning the status of the pre-embryo [22].
Modern medical ethics are based on multidisciplinary
and pluralistic approaches to the philosophical, sociologi-
cal and legal perspectives developed over the past four
decades, especially influenced by the horrors of the 2nd
World War. When performing experiments on pre-embryos
one should take the following aspects into consideration:
(a) respect for human dignity, (b) the slippery-slope
argument, (c) autonomy rights of the patients and (d)
benefits [23].
The central question regarding the ethical problem of
pre-embryo research is the moral status of the pre-embryo.
There are three options for the definition of the moral
status: (a) the pre-embryo is an integral part of the
mother’s own body, (b) the pre-embryo is a potential
human being and (c) the pre-embryo has the full status of a
human being. According to the option that the pre-embryo
is an integral part of the mother’s body, the mother has the
right to abort the pre-embryo and to permit research on it
in accordance with the Helsinki declaration. The conse-
quences of the definition that the pre-embryo has the full
status of a human being are: (a) the pre-embryo has its own
rights, (b) the interest of the mother are irrelevant to the
future of the pre-embryo, (c) there is no justification for
induced abortion for maternal sake and (d) the mother is
regarded only as the guardian or procurator of her pre-
embryo. The definition that a pre-embryo is a potential
human being is a new philosophical entity that com-
promises between the other two definitions, and is the one
accepted today. Even though the pre-embryo is a potential
human being it should be handled with dignity and its
rights should be kept as long as they do not harm major
social and maternal interests or other interests [24].
A basic decision should be made as to the question of
when the status of a potential human being is acquired: (a)
at conception, (b) when implantation occurs and (c) with
the appearance of the primitive streak. It is almost im-
possible to reach a definite consensus about such an issue.
Acceptance of the definition that the status of a potential
human being is acquired with the appearance of the
primitive streak resolved most of the ethical questions
concerning pre-embryo research so far [25].
The legal status of the pre-embryo is also difficult to
establish. If one suggests that it is a person or even a
potential person, it has no legal status according to the law
in most countries [26]. There is a suggestion that the
embryo is property, and by definition it offends ethical
principles. The above suggestions leave open the legal
question of the right to use, to dispose, to sell and to
purchase an embryo. A pre-embryo or embryo seems not
to be a human being for purpose of criminal law. Deliber-
174 S. J. Fasouliotis, J.G. Schenker / European Journal of Obstetrics & Gynecology and Reproductive Biology 90 (2000) 171 – 180
ate destruction of a pre-embryo is not a criminal ‘abortion’
act.
Judicial protection of the pre-embryo may be difficult to
achieve except through legislation. The legislation regard-
ing storage of pre-embryos in the United Kingdom and
Australia and regulations in other countries give the
gamete donors the right to decide its fate [26–28].
According to the wish and consent of the gamete donors, it
can be disposed of, donated to other couples or given for
research. There is a general consensus that the preim-
planted pre-embryo is not a person but should have its own
legal rights, and should be treated with special respect
since it may become a person.
There are differences of opinion among the various
ethical committees concerning the issue of embryo re-
search, but all of them agree that the following procedures
should be forbidden: (a) cloning, (b) inter-species fertiliza-
tion, (c) genetic manipulations and (d) transfer of human
embryo to another species [25].
4. Embryo cryopreservation
Human embryo cryopreservation is a fully established
adjunct to ART. While many embryos may be produced
during a single IVF cycle, the common code of practice
allows physicians to transfer to the uterus only three
embryos in any cycle in order to reduce the likelihood of
multiple pregnancy. Therefore, the extra embryos are
cryopreserved for transfer in a future cycle. Embryos may
also be frozen when the woman’s health may be at risk if
any embryos are immediately replaced. Cryopreservation
of embryos may also have a function in enhancing
implantation, pregnancy and live birth rates [29].
The ethical, legal and religious aspects associated with
cryopreservation of embryos were discussed by profession-
als and by the public prior to implementation of this
procedure [30]. In some countries, the procedure was
heavily criticized by the public, and was stopped until a
regulation or law was passed. Also, those arguing against
cryopreservation of human embryos felt that the practice
would threaten the dignity of humans.
The maximum storage period of human cryopreserved
embryos represents an issue of dispute [31]. Currently,
legislation or regulations covering ART practice in each
country determine this period in the majority of countries
[9]. Thus, a maximum 10-year storage period is set in
Finland, Israel and Spain. On the other hand, in Austria
and Denmark the period is 1 year. Other countries practice
cryopreservation with no limitation on the storage period.
Several ethical committees have recommended that em-
bryos should not be stored for .10 years due to the legal
and ethical complications that may arise if the couples
whose gametes had been used died, separated or divorced,
and because there is little knowledge about the possible
effects of long term storage. As legislation currently
stands, if cryopreserved embryos have not been used for
any purpose for which consent has been given by the end
of the maximum storage period, they should be allowed to
perish.
However, this possibility raises great concerns, as a
large number of embryos will be left to perish when they
cannot be used for treatment. Thus, the question of
extending the maximum storage period has been raised.
The UK Human Fertilization and Embryology Authority
(HFEA) has recently concluded that the storage period for
medical or social reasons can be extended up to 10 years,
with an option to allow extension beyond 10 years in
exceptional cases [32].
The time is approaching when society will need to
determine who (if any one) should receive relinquished
embryos. Embryo donation or usage of the cryopreserved
embryos seems to be medically and ethically justified.
Also, research programs should be encouraged, instead of
permitting the destruction of cryopreserved embryos.
5. Age and assisted reproduction
There is a growing trend among modern day women to
delay childbearing, so that there is a greater proportion of
older women among those who attempt pregnancies. The
result of this is an increase in the rate of pregnancies in
older age groups. Advanced maternal age is associated
with an increase in maternal and fetal morbidity and
mortality. Recent advances in medicine and the advent of
ovum donation (OD) programs have enabled the intro-
duction of oocytes into the uterus of menopausal and
postmenopausal women. The uterus seems to retain its
receptivity to embryo implantation beyond the age of
natural menopause as long as sufficient doses of exogenous
estrogens and progesterone are administered. The success
of the procedure seems not to be influenced by age. This
raises several important ethical issues regarding the wel-
lbeing of both mother and child [33]. Should certain limits
be imposed in applying the method in older women?
There is an innate imperative to reproduce. In the era of
advanced knowledge in the maintaining of a youthful
habitus, a menopausal woman may not feel too old to have
a child. Modern society protects the individual’s right to
privacy and reproductive choice. Couples who were de-
prived of their natural ability to reproduce will divert a
tremendous amount of personal energy as well as resources
in order to achieve conception. Women with premature
ovarian failure have no other options for achieving preg-
nancy other than through OD. Denying oocyte donation to
these women constitutes a denial of their reproductive
choice. Life expectancy at 50 is long enough to enable a
healthy woman to raise a child to adulthood. Society does
not view men and women equally when it comes to age, so
that an older woman is considered unable to have a child,
whereas a man would be considered able to do so. This
 S. J. Fasouliotis, J.G. Schenker / European Journal of Obstetrics & Gynecology and Reproductive Biology 90 (2000) 171 – 180
cannot be ignored since women do bear children, deliver
them and nurse them, whereas men do not. Therefore the
medical risks are to the woman and not the man. Recent
societal changes enable women to choose to have a career
first and delay childbearing to a later age. Some women
find themselves in a second marriage desirous of a child
with their new partner. Others may have lost their children
to cancer or war. Some women have primary infertility,
which at each point in time could not be solved by the
available technology until they reached menopause, by
which time their only option is OD. It may appear as
cruelty or unfairness to deny her access to OD, her first
chance of reproduction, on the grounds of her age alone
[34].
Opponents to OD in the older woman may base their
arguments on the interests and welfare of the potential
child, implying that older individuals are less capable of
coping with the physical and psychological stress of
parenting. Having parents of advanced age may cause
children to endure a greater generation gap or the lack of
grandparents. On the other hand, financial and professional
security and a greater motivation for parenthood usually
characterize older couples. Taking all this into considera-
tion makes it a reasonable supposition that the interests of
the child would be better served by being born to older
parents than to never exist at all [35].
The majority of medical centers offering ovum donation
in order to lessen the risks that might appear in the
involved woman usually warrant a complete medical and
psychological evaluation. Mortality, in a carefully moni-
tored pregnancy, is an extremely rare event. Appropriate
screening of potential candidates and careful obstetrical
management can mitigate perinatal morbidity and mortality
rates. Good education, thorough counseling and an exten-
sive evaluation should be applied in all cases. If this is
performed diligently then the woman would be protected
from harm. The only contraindications to ovum donation
are medical or psychological conditions of the recipient
under which a pregnancy would be ill-advised [36].
Any possible restriction, which may be desired in cases
of OD, must be based on medical, psychological and
ethical issues [37]. Reproduction is a fundamental right in
a free society. Denying oocyte donation to a population of
women who must rely upon it to procreate essentially
negates this freedom. There arises the issue of age
limitation in the postmenopausal group. Some suggest that
this limit should be 60, considering the average life span in
developing countries to be near 80. The writings in the
media are harsh relating to this issue. Doctors who attempt
OD in the older woman will likely be accused of tamper-
ing with nature, acting irresponsibly, or playing God.
Those who will oppose may be accused of arrogance,
sexism and paternalism. Recent surveys, assessing com-
munity attitudes toward OD to postmenopausal women
reveal only minority support for this practice [38].
In conclusion, it is essential that guidelines be estab-
175
lished so that pregnancy can be achieved with minimal
harm to the mother and child. Nevertheless, taking into
consideration the mother and child’s welfare an age limit
should be set. We believe that this should be 55 years of
age [39].
6. Multifetal pregnancy reduction
Multifetal pregnancy reduction from the early days of its
application has been questioned by several authors, in view
of the ethical, legal and social issues arising from the
procedure [40]. There seems to be a general consensus in
society that selective termination is acceptable in multiple
gestations where one or more fetuses are determined to be
severely abnormal [41] or where continuation of the
multiple pregnancy represents a clear threat to the life or
health of the mother, and reduction of fetuses may lessen
the risk [42].
In cases where neither of these risks is present, selective
termination of presumably healthy fetuses could be consid-
ered a type of abortion. It could be argued that in a society
where abortion is available on demand, a multifetal
pregnancy reduction procedure requires no additional
rationale. However, in the debate over abortion, opinions
are considerably diverse. Clinics carrying out selective
termination claim that the procedure should not be consid-
ered as an abortion since the point of selective termination
is the continuation of life and not the termination of the
pregnancy, thus differentiating the procedure from abor-
tion. On the other hand, there are physicians who do not
approve abortion and presumably are opposed to any form
of selective termination, considering it as an action taken
to cause fetal death, which is a criminal offense [43].
If one ignores social and economic issues and concen-
trates entirely on those of medical relevance, the existing
data indicate that multifetal pregnancy reduction effective-
ly reduces the risk of very early preterm delivery with its
associated increase in perinatal mortality or severe mor-
bidity [44]. We have shown [45], that the survival rate of
quintuplets or higher-order gestations after reduction is
75.2%, whereas that of quadruplets also after reduction is
88.7%, survival rates which are much higher than those
that would probably be achieved, if the multiple pre-
gnancies were allowed to continue without reduction (40%
for quintuplets and 78% for quadruplets).
Multifetal pregnancies leading to deliveries are also
associated with an increased socioeconomic strain to the
family. Parents often face severe social and economic
problems when they have to deal with the raising of two,
three or more children resulting from a multiple preg-
nancy. Multifetal pregnancy reduction can be used to
alleviate these worries by decreasing the number of fetuses
carried in a multiple pregnancy [46]. The British Medical
Association recently announced, as a result of the request
of a single mother to reduce her twin pregnancy to a
176 S. J. Fasouliotis, J.G. Schenker / European Journal of Obstetrics & Gynecology and Reproductive Biology 90 (2000) 171 – 180
singleton for social reasons, that no ethical precepts have
been violated and that no laws were broken.
Multifetal pregnancy reduction has been established as
an efficient and safe way by society and especially the
involved population (couples, physicians) in improving the
outcome of multifetal pregnancies and thus in most nations
the opportunity of fetal reduction is provided to IVF
patients. Until advances in assisted reproductive technolo-
gy eliminate the iatrogenic cause of multiple gestation,
multifetal pregnancy reduction offers hope for a good
outcome in an otherwise dismal situation.
7. Preimplantation genetic diagnosis
Preimplantation genetic diagnosis (PGD) is a very early
form of prenatal diagnosis aimed at eliminating embryos
carrying serious genetic diseases before implantation [47].
The main objectives of PGD include an effort to offer the
widest possible range of choices to women at risk of
having children with genetic abnormalities; to provide
reassurance and reduce the anxiety associated with re-
production, especially among women at high risk; and to
enable women at high risk to continue a pregnancy by
confirming the absence of certain genetic diseases. The
emphasis is placed on the provision of life for new
children who may otherwise never have been born.
The great advantage, that enhances the acceptance of
PGD by social groups, is that it avoids the implantation of
defected embryos and this process of selection eliminates
the need for future termination of pregnancy [48]. Preim-
plantation diagnosis, thus, avoids all the debates related
with the issue of abortion in society and in individual
cases, reduces or prevents the suffering for the affected
family, fetus and society and also protects the society’s
resources.
Preimplantation gender selection, another social conflict-
ing issue, is already practiced in some centers. Gender
selection can be used in order to avoid the almost 300
X-linked recessive diseases that are known today. Typical-
ly, healthy female carriers of a defective gene of their
X-chromosomes transmit the disease to their offspring:
females are generally healthy (50% being carriers like their
mothers), but half of the boys will be affected. In genetic
conditions, like Duchenne muscular dystrophy or
hemophilia, which affect only males, while the exact gene
defect may not be known, examination of the DNA of the
biopsied cell can determine the sex of the embryo and thus
only female embryos replaced [49].
Family balancing through PGD remains an issue of
debate. The subject raises such concerns and emotions that
people generally have very polarized views: those wanting
complete freedom to choose however they please the sex
of their child and those that demand the total prohibition of
sex selection for non-medical purposes. The objection to
sex selection arises from the examples of countries like
China, Korea and the Middle East in which boys are highly
prized for economic, hereditary or religious / cultural
reasons. The financial hardship of raising girls in some of
these countries has led to the abandonment of female
children and the widespread use of abortion and infanticide
in favor of boys and this would ultimately alter the
established sex ratio. Family balancing as a procedure
strikes an equilibrium between too much control and too
much freedom [50].
The advocate of PGD has also been related to a future
possible use for the detection of polygenic disorders. The
clarification of the multiple genetic factors responsible for
a large part of the susceptibility to diseases such as
diabetes mellitus, coronary heart disease and malignancies
will greatly affect the moral problems. The genetic in-
formation obtained by PGD may in the future affect
specific individuals and family members. There are several
late-onset genes, perhaps even genes predisposing to
cancer, where diagnosis could result in the carrier being
‘typed’ socially for the affliction by employers, insurance
societies and even by potential marriage partners [51]. A
positive diagnosis of, for example, the dominant gene for
Huntington’s chorea in a fetus implies that one of the
parents or a child is affected, and must face the personal
consequences of this diagnosis. All these pose problems of
confidentiality that could conflict with the duty of disclo-
sure. The provision of information should be limited to the
concerned person or persons, as disclosure of information
to certain societies may be used not for the benefit of the
concerned individual. This scenario enhances the need for
confidentiality as a primary importance in PGD, but also
increases the desire for introducing alternative strategies
including even gene correction for improvement of as
many human individuals as possible [52].
8. Surrogacy
A surrogate mother is defined as a woman who carries a
fetus and bears a child on behalf of another person or
persons, having agreed to surrender the child to this person
or those persons at birth or shortly thereafter. There are
mainly two forms of surrogacy: partial and complete.
Partial surrogacy is defined as the insemination of a
strange woman with the sperm of a man under the
provision that when she delivers the baby, she will return it
to the owner of the sperm. Complete surrogacy is defined
as the transfer of an embryo — conceived by the gametes
provided by both parties of the commissionary couple —
into the uterus of another woman, who after the delivery of
the baby is obliged to return it to the commissionary
couple [53]. Surrogate motherhood may be utilized in
cases of uterine infertility or in cases of severe maternal
disease during pregnancy. Described first by Utian’s group
[54], the procedure engendered complex ethical, social,
 S. J. Fasouliotis, J.G. Schenker / European Journal of Obstetrics & Gynecology and Reproductive Biology 90 (2000) 171 – 180
moral and legal controversy, and has not received as wide
an acceptance as egg donor–recipient pregnancy.
Surrogacy offers several advantages for the commission-
ary couple but debatable is the role and outcome for the
surrogate mother. It is apparent that the parties to a
surrogacy arrangement, not least the children, will be in an
exceptional position with regard to the rest of society. The
problems of being different or having an ‘abnormal’ family
structure have long been recognized. An exact evaluation
of the needs of this small group of people have yet to be
evaluated but it is apparent that many of the problems
potentially associated with surrogacy lie within the field of
the professional social worker. Pretreatment assessment
and counseling, usually in the treatment centers, but also
during and after the initiation of the procedure may enable
the collaborating parties to assess and manage their social
and psychological conflicts in a more efficient way [55].
The extent to which surrogacy arrangements may
provoke less adverse public opinion and become more
socially acceptable remains an issue of dispute, among
legislators and other interested political and legal decision
bodies [56]. The general trend seems to be to view
arrangements, certainly of the ‘compassionate family sur-
rogacy’ variety with increasing favor.
Exceptions, to the already announced good primary
results, still occur and adverse comment arises whenever
there are additional complexities in an arrangement. Cases
where the recipient couple refuses to accept the newborn
because of a congenital malformation or chromosomal
aberration have already been published, confusing and
complicating even more the appropriate legal approach to
the issue of surrogacy. Surrogate mothers who are still in
conflict over access to their child are also known. It is
tempting to suggest that the risk of such problems and the
adverse comment they attract would, potentially, be re-
duced with greater counseling and assessment of intending
surrogacy. Provisions for that are included in the Human
Fertilization and Embryology Act in 1991 and, although
not guaranteed to avoid problems, as these cases demon-
strate, it is obvious that such support is one of the
advantages or ‘inducements’ associated with a nonprohibit-
ory state regulatory system [57].
One major social and ethical aspect associated with
surrogacy, and may be limiting its wide application,
involves the fear of financial exploitation of the suffering
couple, that is commercializing surrogacy. As a safeguard
to this risk, it is proposed that the support needed to
minimize risk to all parties might best be provided by the
state regulation of surrogacy. In 1991 the Ministries of
Health and of Justice in Israel nominated a public commit-
tee to inspect the social, ethical, religious and legal aspects
of assisted reproduction. According to the committee’s
recommendations, the Knesset passed a law in 1996
concerning the practice of surrogacy in Israel. The law
became possible only after the committee managed to
satisfy the Jewish Orthodox (major religious group) estab-
177
lishment requirements. As a result, only full surrogacy is
allowed, and the surrogate mother has to be single or
divorced. Social aspects of the law are that commercial
surrogacy is forbidden, and the surrogate mother has to be
anonymous and not a relative of either party. The new
surrogacy law sets principles to protect the legal rights of
the surrogate mother and to establish the legal position of
the offspring [58].
9. Cloning
Cloning is a biological mechanism of parthenogenetic
reproduction by which one or more genetically identical
cells, organisms, or plants are derived from a single parent.
Although reproduction by cloning is broadly used in plants
and in the biological industry, the achievement of Wilmut
et al. [59], who cloned a mammary cell from an adult
sheep and consequently developed and grew a sheep
embryo to term, set this method of reproduction to medical
and social criticisms as it raised the possibility of replicat-
ing humans through asexual means.
Cloning by nuclear transfer, as an asexual reproduction,
can lead to detrimental biological effects and evolutionary
consequences on the human genome, as well as ethical,
legal, and social implications. In the case of a successful
human cloning, an indefinite cell line will be created,
leading to the loss of the selective advantage of the
organism’s interaction with its environment, which exists
naturally. Several generations of cloning by nuclear trans-
fer increase the risk of an accumulation of deleterious
recessive genes and the possibility of mutations introduced
to the human genetic pool, which may lead to an increase
in various diseases and malformations. Bypassing such
evolutionary processes by missing the natural pathways
may lead to the creation of organisms with morbid or
lethal genes. Such genetic errors would also be reproduced
with the germ-line, thereby ensuring transmission to
progeny. This is the main biological limitation of nuclear
cloning in humans and therefore is unacceptable in clinical
practice [60].
Human cloning by embryo splitting shares certain
advantages over nuclear transfer, as the cloned embryos
are the products of both maternal and paternal gametes
[61]. This eliminates the risk of creating a super human
being or of genetic alterations, and also makes biologically
impossible the selection of elite individuals. During this
micromanipulative procedure the risk of embryo damage
and destruction rises. The increasing experiences with its
application, as well as the clinical advantage of the big
number of ‘back-up’ embryos limit the importance of these
complications. One possible risk for society, arising by the
use of this method, includes the birth of identical embryos
several years apart and also the creation of an unlimited
number of clones. Supporters suggest that limiting the
number of cloned embryos to two and the period of
178 S. J. Fasouliotis, J.G. Schenker / European Journal of Obstetrics & Gynecology and Reproductive Biology 90 (2000) 171 – 180
transfer of embryos to 5 years can control this. After the
successful delivery of the children the remaining stored
embryos should be thawed. Commercializing this process
should be strictly prohibited.
The potential of cloning by embryo splitting for reduc-
ing clinical risks and costs as well as enhancing success
rates for infertile couples who desire children is challeng-
ing. Ovulation induction and oocyte retrieval can be
performed only once and the cloned embryos can be
transferred at different time periods. Such a management
would excessively reduce IVF costs and complications.
Animal cloning is already supported by international
ethical guidelines such as those of the FIGO, WHO,
American Congress and European Council. However,
human cloning is not practiced in any country, and at
present several countries have set legislation that prohibits
its application.
10. Assisted reproduction families: family structure
and the welfare of the child
In spite of the changes that have taken place to the
structure of the family in the latter part of this century, it
remains the case that a family headed by two heterosexual
married parents who are genetically related to their chil-
dren represents the ideal, and that deviations from this
pattern are commonly assumed to result in negative
outcomes for the child.
Families, which have resulted through assisted reproduc-
tion, although continuously increasing in number, may
differ from the normal, either because of non-genetic
relation of one or both parents with the offspring (sperm,
egg, embryo donation, surrogacy) or because of structural
differences, as it is well known that a growing number of
single heterosexual women and lesbian women are opting
for assisted reproduction. Also the creation of these new
types of family raises important questions about the
psychological consequences for the children who result,
and for this reason many have recommended that follow-
up studies of these families should be carried out [62].
Further development is anticipated in the next century in
the field of in-vitro fertilization and assisted reproductive
technology, which will subsequently lead to a more
widespread application of these new technologies. As a
result, an increase in the frequency of these new forms of
family structure is expected, enhancing further the need for
evaluating the family functioning and child development in
such cases.
The social recognition and acceptance of these families,
the social context of them and the processes through which
social environments affect family relationships, are issues
that have raised many disputes and attention [63]. Several
studies have shown that society, either as expressed
through laws or legislation or as influenced by religious or
cultural issues, maintains in the majority of cases a more
compassionate and supporting role to the normal
heterosexual family (marriage or stable relationship), and
hesitating to provide full access to other ‘deviated’ groups.
On the other hand, findings from recent studies suggest
that all these ‘new’ aspects of family structure may matter
less for children’s psychological adjustment than warm and
supportive relationships with parents, and a positive family
environment. Furthermore, several studies have shown no
developmental differences among children growing in
families made out of two heterosexual parents and in
families composed out of lesbian or single mothers [64].
It is our view that society, as we are progressing into the
next century, should not seek to prevent any fertile person,
whatever his marital status, from reproducing, and the
written law or professional bodies should not discriminate
against any group of the society. Each case should be
judged on its merits, leaving aside the question whether or
not infertile couples or single persons have an inalienable
right to a child whatever the method or cost to society or
themselves. With the provision, however, that IVF in
unmarried couples not be carried out without the written
consent of the man involved. Regulatory bodies in coun-
tries dealing with assisted reproduction should set laws or
other statutes through which the welfare of the offspring
should be followed.
11. Conclusion
Assisted reproductive technologies since their evolution
have been implemented with complex ethical, legal and
social issues. No other medical advent has ever raised so
many conflicts among the scientists, the public and the
society as a whole. However, despite all the obstacles, the
medical world has succeeded in establishing this new
procedure and even more to further increase its possi-
bilities and range of treatment in many aspects.
As these techniques are associated with the human being
and his reproduction problems, there is no doubt that their
application will continue to be implicated with many
ethical, legal and moral issues and disputes. Legislations or
other type of regulations will be installed, by many
countries, for the control of any undesired exploitation of
the patient. Society, in every case, should outweigh the
benefits against the risks and set the limits for the
provision of these very useful treatments.
12. Condensation
Advances in human reproductive biology during the last
25 years enabled the introduction and rapid progress of
assisted reproductive technologies; however, a number of
ethical issues still remain unresolved.
 S. J. Fasouliotis, J.G. Schenker / European Journal of Obstetrics & Gynecology and Reproductive Biology 90 (2000) 171 – 180
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