The medical ethics of paid egg sharing in the UK: Opinion

Martin H.Johnson

Department of Anatomy, University of Cambridge, Downing Street, Cambridge CB2 3DY, UK


    Abstract
 Top
 Abstract
 Introduction
 Respect for autonomy
 Justice
 Beneficence and non-maleficence
 Some general conclusions:...
 References
 
Paid egg sharing occurs when infertile patients receive infertility treatment free or at reduced cost in exchange for sharing some of their eggs with patients who require donated eggs. This approach to treatment is discussed in the context of the four principles of medical ethics, namely respect for autonomy, justice, beneficence and non-maleficence. The implications of these ethical considerations for responsible practice and regulation are considered.

Key words: egg sharing/ethics/gamete donation/payment/regulation


    Introduction
 Top
 Abstract
 Introduction
 Respect for autonomy
 Justice
 Beneficence and non-maleficence
 Some general conclusions:...
 References
 
Paid egg sharing involves women or couples (hereafter called `the sharers') who are undergoing fertility treatment, usually by in-vitro fertilization (IVF), receiving free or reduced cost treatment in exchange for sharing some pre-agreed proportion (usually half) of their ovulated eggs with a woman or couple (hereafter called `the recipients') who require egg donation for their own treatment. The recipients cover the treatment costs of the sharers. Eggs may be needed because the recipients have lost all their own eggs, for example through premature menopause, treatment with cytotoxic drugs and/or irradiation, the ageing process, or who can only produce eggs that carry some defect which could be transmitted to the children produced. In this article, I consider some of the ethical issues that paid egg sharing raises. I use as a framework the four basic principles of health care ethics (developed originally by Beauchamp and Childress, 1989Go; Beauchamp, 1994Go), namely respect for autonomy, justice, beneficence and non-maleficence. In applying these principles, there are five parties to consider: the doctor, the sharers, the recipients, the potential children, and, in some societies, the regulatory body which in the UK is the Human Fertilisation and Embryology Authority (HFEA). In the body of the text, I consider the ethical dimensions surrounding the first four parties. The issue of regulation is considered in the last section.


    Respect for autonomy
 Top
 Abstract
 Introduction
 Respect for autonomy
 Justice
 Beneficence and non-maleficence
 Some general conclusions:...
 References
 
A requirement to respect autonomy of thought, intention and action obliges doctors not to treat individuals merely as means to an end. The requirement is tempered to the extent that such respect should be compatible with respect for the autonomy of other potentially affected parties. Respect for autonomy involves consideration of confidentiality, the quality of consents, and the requirement for honesty about, for example, treatment options, risks and likely outcomes. All three aspects of respect for autonomy are also legally regulated in the UK through the Human Fertilisation and Embryology (HFE) Act (1990), but here I concentrate on ethical rather than legal matters. Confidentiality does not seem to raise any issues peculiar to the paid egg sharing situation and will not be considered further.

For consent to be effective, it should be informed and given as free as is possible from pressure or coercion. So in respect of the sharers and recipients, a pertinent question to be asked of each is: if an alternative strategy for treatment were available that did not involve paid egg sharing would that be adopted in preference and if so how strong would that preference be?

Autonomy of recipients
What alternative treatment strategies to a paid egg sharing arrangement are there for the recipient couple? There is a shortage of donor eggs (Birdsall and Edwards, 1996Go; Englert et al., 1996Go). Current licensing practice in the UK prevents use of fetal or cadaveric eggs in infertility treatment (HFEA, 1994). Moreover, UK law prohibits the direct purchasing of oocytes for cash from fertile paid egg donors (HFE Act, 1990). The technologies for in-vitro maturation and cryopreservation of human oocytes recovered from live adult ovaries are not advanced sufficiently to be useful, although this situation may change quite rapidly. Thus currently, both regulatory and technical reasons combine to mean that oocytes are in short supply. There are currently five possible alternative options to paid egg sharing. The first two involve alternative sources of egg supply, namely fertile women (known or anonymous) who are willing to donate eggs without payment (unpaid fertile egg donors), and infertile women who are willing to donate eggs without payment in kind (unpaid egg donors). A third option for recipients is the use of embryo donation, for which payment is not allowed in the UK (HFE Act, 1990). There are large numbers of cryopreserved embryos, and many will never be used in treatment, but will be destroyed or used in research. Embryo donation would presumably be acceptable to recipient women who were being treated without a male partner. For women being treated with a male partner, the issue of genetic unrelatedness to either parent would need to be addressed. A fourth option would be to travel to a treatment centre in a country with less restrictive or no legislation where eggs could be bought on the open market. This approach would be expensive and potentially dangerous, since donor screening might be less effective or non-existent. A fifth option for recipients is to accept that the shortage of egg donors means that their infertility simply cannot be treated, and so to accept their infertility. I know of no research on the relative strengths of preferences of recipients in general for each of these five alternatives to paid egg sharing. However, it is the individual recipient who needs to consider each option. So the ethical course for doctors would seem to be to explain clearly the nature of each course of possible action, its likely availability, its risks, and its medical, biological, legal and ethical consequences, and to establish a clear order of preference for each patient couple individually. Is this always done? Indeed are doctors sufficiently informed and dispassionate to do it alone or should counsellors undertake all or part of the task?

Autonomy of paid egg sharers
What are the alternative strategies for the paid egg sharing couples themselves? They have two options in addition to paid egg sharing. They also could decide to accept their infertility and forgo further treatment. If this course is not acceptable, then they have to decide between paying for treatment or paid egg sharing. If they pay for treatment, they retain the option of unpaid donation of their eggs if they so wish, so any desire on their part to help others through egg donation is not material to the question under consideration. The dilemma for them comes if they cannot (or will not) afford to pay for treatment and so perceive that their only access to treatment is through paid egg sharing. Such a route amounts formally to being paid for their eggs, a payment in kind of value worth £900–2500 or more at current treatment costs. Again, I know of no study which shows what the order of preference of each of these three options (acceptance of infertility, paid egg sharing or paying for a treatment cycle) would be in the general population, but again it is the individual couple that needs to be given the same sorts of information as for recipients (see above), and about which the same questions arise. If acceptance of infertility is not the route chosen, anecdotal evidence from personal testimonies by paid egg sharers, as well as the very low incidence of unpaid egg donation by the infertile, both suggest that recourse to paid egg sharing would be a last resort if a true choice between the two treatment options were available. Given these circumstances, there must be some doubt as to whether consent to paid egg sharing can be fully effective and freely given, if the patient couple feel they have no choice in the matter due to financial distress. There also exists the clear possibility with paid egg sharing that some couples who could afford to pay, none the less claim not to be able to do so in order to circumvent the ban on direct payment for eggs. In these cases, the payment would be acting as an inducement, which again might be considered to impair the quality of consent (see discussion on payment under justice). However, it might be argued that even £2500 is not a sufficiently large sum to be an inducement or coercion in contemporary Britain. Of itself that is possibly a defensible assertion. However, when the decision to consent to paid egg sharing is linked with the strong desire to produce a `virtual' child that is in a sense beyond price, does the combined value become so magnified as to invalidate the consent?

Patient autonomy and the doctor
Doctors face a number of difficult and inter-related ethical issues to resolve in fully respecting the autonomy of patients in this situation. First, given the difficult choices faced by both recipients and sharers, it is arguable that an ethical medical approach would demand that the doctors treating the recipients should not also be treating the sharers. For the same doctor or team to be treating both might easily lead to conflicts of interest and might compromise the ability of the doctor to fully take account of the requirement for respect for autonomy of one patient to be fully compatible with respect for the autonomy of the other potentially affected party. Second, given that most treatment is privately funded and that the issue of the requirement to pay fees lies at the heart of the dilemma for the sharers, how ethically sound is it that a doctor with a vested financial interest in the treatment of the sharers should be advising them on egg sharing, since fees to the doctor for two rather than one or no course of treatment would result from the sharers' consent? Third, given the uncertain effectiveness of the sharers' consent, is there a risk of them being used as a means to an end? Clearly they are not `merely' a means to an end, unless the treatment outcome for the sharers is demonstrably of a very low probability of producing a child (in which case the honesty in information sharing would be compromised and so unethical).

Summary
With respect to the principle of autonomy, there must be considerable doubt about the validity of consents to proceed with a paid egg sharing arrangement. The processes of information giving and patient choice and the potential for inducement and coercion all seem problematic.


    Justice
 Top
 Abstract
 Introduction
 Respect for autonomy
 Justice
 Beneficence and non-maleficence
 Some general conclusions:...
 References
 
Whilst respect for autonomy emphasises the individual nature of the patient or patient couple, the principle of justice sets that individual within a social context that may involve the doctor in the explicit adjudication between competing claims in three main areas, namely distributive justice of scarce resources, competing needs, rights and obligations, and potential conflicts with laws that have been passed by a process that is morally acceptable.

Distributive justice
In the context of treatment for infertility by the new assisted reproductive technologies, any specific treatment issue is problematic in terms of distributive justice. Thus, most but not all treatments in most but not all parts of the UK are only available privately, costs vary widely between different private treatment centres, and the distribution of treatment centres is also uneven. There is inequality of patient (and doctor) access both to treatment and to free or low cost treatment. The reasons for this inequity of provision are not obviously justifiable, and thus the situation represents an institutional injustice against which back-drop the specific issue of paid egg sharing must be set. It is a pertinent backdrop for sharers, since their dilemma is whether or not to pay for their own treatment or to have it paid for them by the recipients in exchange for their eggs. It is pertinent for receivers, since it affects the likely total cost of their treatment and that of their donors for whom they are paying.

It is not a requirement of justice that all needs be met. It is sufficient that needs be heard, considered, weighed against other needs, discriminating criteria be established fairly, clear explanations be given for meeting or not of the needs, a comparability of outcome be aimed for nationally, and appeal or recourse to alternatives be possible. Manifestly, such justice is not available to all potential sharers and recipients at an institutional level nationally. Individual doctors cannot do much about that other than campaign. However, the principle of justice does require each doctor, having explored with each patient whether and how their needs for treatments other than through paid egg sharing might be met, to help them achieve their agreed choice. Given the background of national injustice, is there also an obligation on doctors to attempt to set up systems which circumvent the problem, thereby to restore some individual justice? For example, doctors might charge for all treatment cycles according to some pre-specified measure of ability to pay rather than simply of medical need, with a sliding scale of charges that eliminated the financial pressure to be sharers, whilst retaining for patients the option to share without pressure. They might do this individually or collectively through professional associations, thereby ameliorating institutional injustice. This suggestion is not totally outrageous, since there is anecdotal evidence that this happens already in an informal and unsystematic way in individual clinics and that such a system was operated for more general treatment provision by some doctors prior to the establishment of the National Health Service.

Competing needs, rights and obligations
The second sort of issue to consider under justice is the effect of payment in kind for eggs on society as a whole, in the context of the inter-relationships and mutual duties and responsibilities that individuals within society have to each other. Such a discussion needs to be set against a background in which societies within the European Community have effected or recommended prohibition of direct payments for body parts including gametes (Nuffield Council on Bioethics, 1995Go; Council of Europe Convention, 1996Go). This prohibition on payment is pertinent because the issue for egg sharers is how to pay for treatment. If buying and selling eggs were allowed, paid egg sharing might well not be an issue for infertile egg sharers since any fertile woman could sell her eggs, as is done in the USA for over $2000 per cycle, the market price setting the supply (Sauer, 1996Go, 1997Go). It has been argued that the prohibition of a free market in any body parts or tissues conflicts with respect for an individual's autonomy (Radcliffe-Richards et al., 1998Go). Thus, it is argued, as long as counselling and impartial advice are provided sufficient for effective consent, together with some sort of regulatory supervision of this process, why should a person not sell one kidney in order to buy something much needed such as food for a child, an education, medicines, or even a cycle of IVF treatment? After all, there are two kidneys and in the unlikely event that the remaining kidney failed, there would be in place a market scheme to purchase one back much more readily than would be obtainable now. The prohibition on selling body parts, it is argued, represents an infringement of autonomy. Whether consent can be truly effective under inducement or pressure was discussed earlier: it is arguable that autonomy has already been so far infringed by the inability to afford treatment as to render it illusory. There is, however, a broader dimension to the question relating to justice.

There is a widespread and powerful reaction against the selling of kidneys or blood. This seems to derive from the concept that people should be encouraged, helped and if needs be compelled to act in the common good and that it is worth yielding some individual autonomy to this end. Such a view is the basis on which ordered society rests, and why we have laws and conventions. Without an implicit commitment to yield autonomy to social order, there is anarchy. The reaction against payment for body parts seems to rest within that European social tradition (Englert, 1996Go; Sauer, 1996Go). The principle of justice requires that others' rights and needs be respected, and the right to donate and receive body parts without payment seems to be embedded within this view. Trading by some in body parts weakens the rights of the whole population not to be regarded as commodities or be instrumentalized. Further, the selling of body parts might put the general population at risk in that it might both distort and even reduce the supply by negatively motivating donors and positively motivating only the desperate and possibly the suspect or deceitful (Titmuss, 1970Go; Dodd, 1985Go). Gametes and embryos can be considered as body parts, and there is a similarly expressed reluctance in the UK that payment should be involved in their donation (Power et al., 1990Go; Cook and Golombok, 1995Go; Abdalla, 1996Go; Johnson, 1997Go).

However, the argument about selling kidneys differs from that about selling gametes and embryos in one important respect. The sharers are in essence being paid for their eggs. These eggs are being provided with the express intent of creating a child for the recipients. So there is an issue of whether such a transaction amounts to the instrumentalization of the child by trading in intended persons and so breaches respect for the potential child by treating it as a commodity rather than as an end in itself. There is also a need to consider how the child's knowledge that its conception involved a substantial financial transaction might affect it or its status in the eyes of society. It might be argued that, since in most cases assisted conception treatment is only available privately, most patients are in effect engaging in a commercial trading transaction anyway. However, the distinction between paying for health care services and paying for body parts is important and very clearly established. Thus, the fact that blood may be given or organs donated does not preclude the doctors and nurses involved being paid and other costs covered. Egg sharing rather worryingly blurs this clear distinction and thus has the potential to undermine the inherent distinction. Is this desirable ethically? For all these reasons gametes would seem to be a harder case than kidneys. Does this mean that kidney sales should be allowed before sale of gametes is allowed? If so, the principle of justice, as viewed within the European social and ethical tradition, seems to be weighted against paid egg sharing.

However, it may be counter argued that egg sharing by the infertile, whether paid or not, differs fundamentally from the sale of gametes because it is a mutual act of sharing amongst the similarly afflicted (Ahuja and Simmons, 1996Go; Ahuja et al., 1999Go). By helping someone else, they help themselves and so promote a social ethic that supports rather than undermines social justice. This seems a powerful argument. It rests upon an assumption of social altruism which, if real, might be supportable by corroborative evidence. For example, if there were a socially altruistic community of the infertile, we would expect to see: a high proportion of couples with spare frozen embryos consenting to make them available for the treatment of others by donation; the male partners of couples undergoing IVF for female-based infertility prominent among sperm donors; and evidence that unpaid egg sharing was widespread. In the absence of that corroborative evidence, which does not seem to exist, it remains possible that the mutual advantage gained from paid egg sharing is only a by-product of the inadequate quality of consent of the sharers. Of course, it could well be argued that when paid egg sharing does occur the altruism is none the less real, and that it is not reasonable to expect a purely altruistic action devoid of practical benefit to the altruistic. Certainly one would not want to devalue any altruistic intent in such situations. However, the ethical dilemma is: can the impairment of the principle of autonomy involved in establishing a paid egg sharing arrangement be offset adequately by the application of this principle of justice, and if so how?

For example, might doctors and patients conspire to form a genuinely altruistic community by agreeing to set up a system in which all those undergoing treatment by IVF accepted that a `tax' of some percentage of their recovered eggs be levied, so that a pool of freely donated eggs be available for donation. In the UK, there would be legal problems concerning the pooling of eggs from different women and the uncertainty about the genetic parenthood in such a system, but might it be responsible to at the very least explore options like this one as a way of potentially resolving the current problem of egg shortage?

Upholding the spirit of the law
The third aspect of the principle of justice is that it requires the doctor to confront and to resolve potential conflicts with laws or directives that have been passed by a process that is morally acceptable. For example, the doctor or the doctor's patients may disagree with a law, but if that law has been passed by a democratic process with due examination and discussion of the evidence and in which the doctor or the doctor's representatives have been given the opportunity to participate, then there is a moral as well as a legal obligation on the doctor to apply the law. The doctor may campaign to have the law changed, as may the doctor's patients, although it is debatable morally whether she should encourage or incite them to do so. In the context of paid egg sharing in the UK, the law prohibits payment for gametes, but includes a discretionary clause `unless authorised by Directions'. With the introduction of the HFE Act in 1991, the HFEA issued such a Direction that prohibited payment for eggs in any programme of donation set up after the Act became effective. It did allow benefits in restricted circumstances for the provision of treatment services and sterilization.

The medical profession had a major input into the drafting of the law, and retains a major influence on the issuing of Directions and the development of the HFEA Code of Practice. It does this through both its (legally circumscribed: Johnson, 1998Go) membership of the HFEA, through extensive formal and informal contacts with the HFEA, and through membership of HFEA committees. It thus has had an access to the development and application of the HFE Act unrivalled by any other interested party. So doctors could be considered particularly bound to support the legal intent and spirit of the Act, whether they personally agree with all the legislation or not. The Direction forbidding payment for eggs makes it clear that it would not be legal in the UK for the recipient to pay the sharer £2000 for eggs and for the sharer to then pay the doctor £2000 for a treatment cycle. The fact that in paid egg sharing the £2000 is paid directly by the recipient to the doctor who then provides a free treatment cycle for the sharer is within the letter of the law, but arguably not within its spirit. Does this lie morally within the principle of justice as far as the doctor is concerned?

Summary
The ethical arguments about paid egg sharing under the principle of justice are less unbalanced than those concerning autonomy. It seems reasonable to expect doctors to conform to the spirit of the relevant law, which offering an egg sharing service does not obviously do. It also seems reasonable to expect doctors as a profession to act in ways that ameliorate injustice so as to reduce the need for paid egg sharing given the problematic consent issues. It is also the case that the practice of paid egg sharing sits very uneasily with general social attitudes on altruism, including those of the infertile community at large, and that it might also contribute to a more general erosion of social altruism and an increasing instrumentalization or commodification of people. However, to set against these points, it is arguable that once infertile couples have agreed to enter a paid egg sharing arrangement, however flawed ethically that entry process may be, a genuinely altruistic element may develop which sits well within the principle of justice.


    Beneficence and non-maleficence
 Top
 Abstract
 Introduction
 Respect for autonomy
 Justice
 Beneficence and non-maleficence
 Some general conclusions:...
 References
 
These two principles are taken together because they are interlinked. The duty to do good must take account of the possibility of doing harm and the doctor in striving to maximize the former should aim to minimize the latter. These principles require a doctor to develop and maintain skills and knowledge, to be up to date and enquiring, to treat patients as an individual so as to optimize their treatment to their circumstances, to be clear about risk, and to strive for net benefit.

The requirement on the doctor to strive to maximize the outcome of each cycle of therapeutic IVF so as to achieve the best live birth rate attainable as assessed by comparison with other clinics and due regard to patient profile (HFEA, 1997) comes under these principles. In fact, different treatment centres have adjusted live birth rates per treatment cycle of IVF initiated ranging from 0% to 28% (HFEA, 1997). The result is that patients at some centres will need more cycles of treatment to achieve a pregnancy and birth, with all the attendant costs involved, than will patients at other centres. Since costs of a treatment cycle also vary, they can be combined with outcome rates to produce the cost of a treatment cycle per live birth per centre, estimated to be £5325–£41 939 (Dawe, 1997Go). This range is very large. Clearly, were all clinics to be as effective as the best, the pressure on many patients to agree to be paid egg donors would be substantially reduced.

In addition, centres should use all eggs for donation, by whatever route obtained, in optimal organizational and clinical procedures (Englert et al., 1996Go). Alluded to earlier is the obligation to advance the technology of treatment by promoting, performing, testing and applying research on human oocyte maturation in vitro and human oocyte cryopreservation. Doctors might also consider how best to support the promotion in general of other sources of existing types of unpaid egg or embryo donors. Finally, doctors might re-open discussion on the use of cadavers as a possible source of donor eggs. Each of these activities falls within the principles of beneficence and non-maleficence, and might reduce the pressure on patients to share or receive eggs by payment in kind.

These are general actions. More parochially, in the context of specific paid egg sharers and recipients, it is clear that both could be said to benefit by paid egg sharing, in the sense that they both have the opportunity of receiving treatment which was otherwise not available. This argument must seem very beneficent to the ethical and sensitive doctor, since it solves the problems of two sets of patients in one procedure. However, this conclusion needs to be examined in respect of two sorts of issue.

The first point is that the statement that either there is paid egg sharing or there is nothing is unduly bleak. These are not the only alternatives, as was described earlier, and stating the potential outcome in this way places undue emphasis on an apparently beneficent outcome at the expense of flawed and thus potentially maleficent process. Clearly the ends cannot always justify the means, although in contemporary society, including medicine, there is an undue emphasis on outcome and outcome measures that can devalue the important process elements required to get there. Consideration of the principles of respect for autonomy and justice has exposed a number of difficult dilemmas for paid egg sharing which cannot simply be swept away by an apparently beneficent outcome measure. A balance must be struck where principles appear in conflict, and process and outcome aspects should have comparable weight. Unless or until procedures and structures can be put in place that address adequately the compromised justice and autonomy issues, there must be some doubt as to whether a truly beneficent outcome untainted by maleficence can be achieved.

The second consideration arises from this first point. Alternative strategies will each have their own ethical dimensions. Here I wish to focus only on those which are relevant in a direct comparison with paid egg donation. First, unpaid fertile egg donors are compared. These differ from paid egg sharers not only in the lack of payment but also in that they would not otherwise be `patients' undergoing treatment were they not donating eggs. Clearly, there are issues around effective consent for such donors and for the information provision required. There are also two sorts of risk that these donors experience to which they would not otherwise be exposed. Thus they must undergo procedures of ovarian stimulation, monitoring and egg collection, which in themselves carry some risk, albeit small enough for the procedures to be routine. Second, anecdotal evidence has led to concern about the possible long term sequelae of ovarian stimulation (Ahuja and Simmons, 1998Go), and although there is no epidemiological evidence for an increased incidence of ovarian cancer with current ovarian stimulation regimes (Bristow and Karlan, 1996Go; Artini et al., 1997Go; Mosgaard et al., 1997Go), it is prudent to advise women undergoing stimulation of a possible unquantified but low risk, especially if they are contemplating multiple courses of stimulation (Rosen et al., 1997Go). Thus, unpaid fertile donors are exposed to two sorts of additional potential risk, albeit in both cases very low risks, which are an integral part of the treatment of paid egg sharers. There is an undoubted element of maleficence in respect of them which is not obviously balanced by any direct personal medical beneficence for the donors themselves.

However, it is not simply the balance of beneficence and maleficence for the donor alone that has to be weighed, but that for both egg provider and recipient taken together. More explicitly, what is required is a direct comparison of this balance for fertile donors+recipients with that for infertile sharers+recipients. First, it is important to point out that paid egg sharers may also be exposed to increased risk as result of sharing. Thus, sharing half of the eggs at each round of stimulation may mean stronger stimulation, and also fewer good quality embryos to replace and/or to cryopreserve, which may result in more cycles of stimulation than would otherwise be necessary. Moreover, the strong drive to achieve a pregnancy may take paid egg sharers closer to a more risky number of rounds of stimulation in respect of longer term hazards than is likely with fertile donors. Second, pregnancy is the major protective factor for ovarian cancer, and fertile donors are thus much better protected than paid infertile sharers. Third, it is possible, but not clear from available data, that recipients may be more likely to become pregnant with eggs from fertile donors. Overall, the use of fertile donors may result in a lower total number of cycles of treatment and a greater level of protection against the risk of ovarian cancer. Clearly, the actual data need to be collected and evaluated carefully. However, medically, the balance of the risk with use of fertile donors may well be less than with use of infertile sharers, and certainly there is no clear presumption one way or the other on current evidence.

The second alternative to paid egg sharing that I consider combines unpaid egg and embryo donors together, since they share many characteristics with each other and with paid egg sharers. In all three cases, treatment for infertility is being experienced. Each is therefore exposed to risk. The only additional risk is for unpaid egg donors who might need more rounds of stimulation to achieve a pregnancy as a result of sharing (see above). Embryo donors will know about their treatment outcome before having to commit to donation, and so this increase in risk does not apply to them.

Summary
There are some general actions that doctors might take under these principles to alleviate the shortage of oocytes. However, the central consideration concerns whether there is a net benefit to all parties with paid egg sharing. Superficially this might seem to be the case. There is clearly a net increase in risk to fertile donors which must be communicated to them clearly. However, the overall risk level to all parties may be less with use of fertile unpaid donors than with infertile paid sharers, and it is not possible on current evidence to be sure. There does not seem to be an overwhelming net advantage of using infertile paid egg sharers.


    Some general conclusions: implications for practice and regulation
 Top
 Abstract
 Introduction
 Respect for autonomy
 Justice
 Beneficence and non-maleficence
 Some general conclusions:...
 References
 
Paid egg sharing poses complex ethical issues. There are conflicting ethical arguments to resolve and balance. There are fundamental problems with respect for patient autonomy, especially for the quality and effectiveness of informed consent, with the potential for a general erosion of social altruism and for the instrumentalization or commodification of potential people. The mutually altruistic relationship of the couples who do proceed to paid egg sharing should not be denigrated or diminished, but the process by which they have arrived at this relationship is highly problematic. It is also not yet possible to be sure that there is truly a net beneficence in such a relationship compared with other routes to handling the infertility. For a doctor contemplating the introduction of paid egg sharing into a clinic, as well as for their patients, these conflicts will need to be weighed very carefully against each other in order to determine whether there is a clear and sufficiently unambiguous ethical imperative in favour of proceeding, and if so, how to proceed ethically.

The regulatory authorities in the UK and elsewhere will also need to weigh these arguments carefully. They will need to consider whether the ethical difficulties are so large as to warrant the prohibition of paid egg sharing, especially when the legal presumption as in the UK is against payment for gametes, or whether there is sufficient balance in the ethical arguments to use legal discretion and put in place a regulatory control of the process. If the decision were to choose the latter route, what might the development of a regulatory framework involve?

First, it is important to hold on to the point that the choice may not simply lie between paid egg sharing and no treatment. There are other options, and there are also other possibilities for more effectively managing egg donation, and all of these need to be explored more closely. The use of cadaveric eggs may now be more acceptable than it was, and a more flexible regulation of egg sharing and pooling might be explored to see whether an egg taxing system could operate. Certainly, it seems desirable that a system be put in place to ensure that potential egg sharers and recipients are fully informed of the alternatives to paid egg sharing and of the consequences that flow from each option. This would help to increase the likelihood of informed consent. The consent process might also involve a `cooling off' period for reflection before initiation of treatment, so as to bolster the effectiveness of the consent. The requirement for effective consent may also make it desirable to stipulate a minimum number of viable eggs retrieved from the sharer before any portion of them is used for sharing, as well as to require a clear specification of the protocols for deciding which and how many eggs to share or retain. It is also arguable that the consent process would be more effective were it independent of the doctors offering treatment and were the interests of potential egg sharers and recipients handled entirely separately. There may be a need for special provisions to be made when assessing the welfare of children born to recipients by paid egg sharing. Provision of reliable data that would establish the relative net benefits or disadvantages of different types of egg sharing arrangements might be sought as part of a condition of licensing.

The general approach of regulatory bodies, backed by legal support, can strongly influence whether social values are maintained or eroded. If the values explicit in the legislation cannot be sustained for practical reasons, then perhaps the law should be changed or at the very least debated by Parliament? Regulatory bodies are also well placed to encourage more effective self-regulation by the medical profession itself, to minimize the adverse ethical features of paid egg sharing. Doctors face a very difficult task in deciding how to behave ethically in respect of paid egg sharing and need a clear regulatory framework that helps and supports them in this task.


    Acknowledgments
 
I am deeply grateful to Onora O'Neill and Liz Forgan for stimulation and advice, and to the referees from Human Reproduction for their stimulating and constructive reports.


    Notes
 
This Opinion was previously published on Webtrack 64, 30 April, 1999


    References
 Top
 Abstract
 Introduction
 Respect for autonomy
 Justice
 Beneficence and non-maleficence
 Some general conclusions:...
 References
 
Abdalla, H.I. (1996) A national oocyte donation society is needed. Hum. Reprod., 11, 2355–2356.[ISI][Medline]

Ahuja, K.K. and Simmons, E.G. (1996) Anonymous egg donation and dignity. Hum. Reprod., 11, 1151–1154.[ISI][Medline]

Ahuja, K.K. and Simmons, E.G. (1998) Cancer of the colon in an egg donor: policy repercussions for donor recruitment. Hum. Reprod., 13, 227–231.[Abstract]

Ahuja, K.K., Simmons, E.G. and Edwards, R.G. (1999) Money, morals and medical risks: conflicting notions underlying the recruitment of egg donors. Hum. Reprod., 14, 279–284.[Free Full Text]

Artini, P.G., Fasciani, A., Cela, V. et al. (1997) Fertility drugs and ovarian cancer. Gynecol. Endocrinol., 11, 59–68.[ISI][Medline]

Beauchamp, T.L. (1994) The four principles' approach. In Gillon, R. (ed.), Principles of Health Care Ethics. John Wiley & Sons, Chichester, UK, pp. 3–12.

Beauchamp, T.L. and Childress, J. (1989) Principles of Biomedical Ethics. 3rd. edition. Oxford University Press, Oxford, New York, USA.

Birdsall, M.A. and Edwards, J.M. (1996) Demand for donated eggs by ethnic minority groups exceeds the supply. Br. Med. J., 313, 1145.[Free Full Text]

Bristow, R.E. and Karlan, B.Y. (1996) Ovulation induction, infertility, and ovarian cancer risk. Fertil. Steril., 66, 499–507.[ISI][Medline]

Cook, R. and Golombok, S. (1995) A survey of semen donation: phase II – the view of the donors. Hum. Reprod., 10, 951–959.[Abstract]

Council of Europe Convention (1996) The Protection of Human Rights and Dignity Of The Human Being with Regard to the Application of Biology and Medicine. Council of Europe, Strasbourg.

Dawe, V. (1997) IVF league shows cost disparity. Hospital Doctor, 10th April, 42–43.

Dodd, R.Y. (1985) Donor screening and epidemiology. In Dodd, R.Y and Barker, L.F. (eds), Infection, Immunity, and Blood Transfusion. Liss Inc, New York, USA.

Englert, Y. (1996) Ethics of oocyte donation are challenged by the health care system. Hum. Reprod., 11, 2353–2357.[ISI][Medline]

Englert, Y., Rodesch, C., Van den Bergh, M. and Bertrand, E. (1996) Oocyte shortage for donation may be overcome in a programme with anonymous permutation of related donors. Hum. Reprod., 11, 2425–2428.[Abstract]

Human Fertilisation and Embryology Act (1990) Human Fertilisation and Embryology Act. HMSO, London, UK.

Human Fertilisation and Embryology Authority (1994) Donated Ovarian Tissue in Embryo Research and Assisted Conception. [Report.] Human Fertilisation and Embryology Authority, London, UK.

Human Fertilisation and Embryology Authority (1997) The Patients' Guide to DI and IVF clinics. 3rd edn. Human Fertilisation and Embryology Authority, London UK.

Johnson, M.H. (1997) The culture of unpaid and voluntary egg donation should be strengthened. Br. Med. J., 314, 1401–1402.[Free Full Text]

Johnson, M.H. (1998) Should the use of Assisted Reproduction Techniques be deregulated? Hum. Reprod., 13, 1769–1776.[Free Full Text]

Mosgaard, B.J., Schou, G., Lidegaard, O. et al. (1997) Infertility, fertility drugs, and invasive ovarian cancer: a case control study. Fertil. Steril., 67, 1005–1012.[ISI][Medline]

Nuffield Council on Bioethics (1995) Human Tissue: Ethical and Legal Issues.Nuffield Council on Bioethics, London, UK.

Power, M., Baber, R., Abdalla, H. et al. (1990) A comparison of attitudes of volunteer donors and fertile patient donors on an ovum donation programme. Hum. Reprod., 5, 352–355.[Abstract]

Radcliffe-Richards, J., Daar, A.S., Guttmann, R.D. et al. (1998) The case for allowing kidney sales. Lancet, 352, 1950–1952.[ISI][Medline]

Rosen, B., Reynolds, K., Irvine, J. et al. (1997) The feasibility of assessing women's perceptions of the risks and benefits of fertility drug therapy in relation to ovarian cancer risk. Fertil. Steril., 68, 90–94.[ISI][Medline]

Sauer, M. (1996) Oocyte donation: reflections on past work and future directions. Hum. Reprod., 11, 1149–1150.[ISI][Medline]

Sauer, M.V. (1997) Exploitation or a woman's right? Br. Med. J., 314, 1403.[Free Full Text]

Sells, R.A. (1994) Transplants. In Gillon, R. (ed.), Principles of Health Care Ethics. John Wiley & Sons, Chichester, UK, pp. 1003–1025.

Titmuss, R.M. (1970) The Gift Relationship from Human Blood to Social Policy. Allen and Unwin, London, UK.