Conceived and Deceived: The Medical Interests of Donor-Conceived Individuals

University students' opinion on gamete donor identification regimes

PURPOSE

This study aims to evaluate the opinion of university students about the identification or nonidentification of gamete donation and the probability of donation according to the different regimes.

METHODS

This was a cross-sectional observational study based on an online anonymous survey including questions about sociodemographic data, reasons for considering donations, information about the donation process and legislation, and their opinions about the different regimes and how they would influence donations.

RESULTS

In total, 1393 valid responses were obtained, with a mean age of 24.0 years (SD = 4.8), most of the respondents being female (68.5%), living in a relationship (56.7%), and without children (88.4%). The main reasons for considering donation would be altruism and monetary compensation. Overall, it was found that participants were poorly informed about the donation procedure and legislation. Students revealed preference for nonidentified donation, and they were less likely to donate in an open identity regime.

CONCLUSION

Most university students consider themselves poorly informed about gamete donation, express a preference for nonidentified gamete donation, and would less likely donate on an open identity basis. Thus, an identified regime may be less attractive to potential donors and lead to a decrease in the availability of gamete donors.

Parent-initiated posthumous-assisted reproduction revisited in light of the interest in genetic origins

A rich literature in bioethics argues against the use of anonymous gamete donation in the name of the 'interest in knowing one's genetic origins'. This interest stems from medical as well as psychosocial and identity reasons. The term 'genealogical bewilderment' has been coined to express the predicament of those deprived of access to information about their origins. Another rich body of literature in bioethics discusses arguments for and against posthumous-assisted reproduction (PAR), with a recent focus on PAR that is initiated by the parents of a deceased man (rather than his partner). This paper revisits arguments against PAR, in light of arguments regarding the interest in knowing one's genetic origins. Limiting the discussion to the specific context of parent-initiated PAR (PIPAR), we argue that the use of cryopreserved sperm from a deceased identifiable man in the context of PIPAR may be ethically preferable when compared with the use of anonymous donor sperm, since it allows genealogical certainty, that is, giving the prospective child access to information about the identity, life story and ancestry of the genetic progenitor as well as genealogical embeddedness, that is, close relationship with extended family members.

Medical ethics when moving towards non-anonymous gamete donation: the views of donors and recipients

Drawing on the views of donors and recipients about anonymity in a country that is experiencing a transition towards non-anonymous gamete donation mandated by the Constitutional Court, we explore how the intersection between rights-based approaches and an empirical framework enhances recommendations for ethical policy and healthcare. Between July 2017 and April 2018, 69 donors and 147 recipients, recruited at the Portuguese Public Bank of Gametes, participated in this cross-sectional study. Position towards anonymity was assessed through an open-ended question in a self-report questionnaire, which was subject to content analysis. Preference for an anonymous donation regime was mentioned by 82.6% of donors and 89.8% of recipients; and all those with children. Instead of the rights-based reasoning used by the Constitutional Court, donors highlighted concerns over future relationships and recipients focused on socioethical values linked with the safeguard of safety, privacy and confidentiality. The remaining participants advocated the choice between anonymity or non-anonymity (double-track policy), invoking respect for their autonomy. The complex, diverse ethical views and reasoning of donors and recipients expand a traditionally dichotomous discussion. Their perspectives challenge the transition towards non-anonymity and international guidelines, raising awareness to the need for their involvement in the design of policies to enable choice according to their values and preferences, and of psychosocial counselling responsive to their socioethical concerns and sensitive to their parental status. Empirical frameworks complement rights-based approaches to uphold justice, fairness and equal respect, and to incorporate utility, beneficence and non-maleficence in policymaking and healthcare in the transition towards non-anonymity.

The forgotten group of donor conceived persons

A forgotten group of donor-conceived persons is those who believe that gamete donation is morally wrong and should be prohibited. Although they share the two main arguments with the anti-anonymity group, i.e. the psychological harm as a consequence of lacking the necessary information for identity construction, and the violation of a fundamental human right, namely the right to be cared for by one’s genetic parents, their voices are largely ignored in the debate. The anti-donation group also has a large part of the ideology of the family in common with the anti-anonymity group. The paper concludes that the anti-donation position should be accepted as an equivalent position. Moreover, given the similarities between the two positions, people who accept the claims of the anti-anonymity donor-conceived persons should explain why the claims of the anti-donation group should not be honoured.

Well-being, Gamete Donation, and Genetic Knowledge: The Significant Interest View

The Significant Interest view entails that even if there were no medical reasons to have access to genetic knowledge, there would still be reason(s) for prospective parents to use an identity-release donor as opposed to an anonymous donor. This view does not depend on either the idea that genetic knowledge is profoundly prudentially important or that donor-conceived people have a right to genetic knowledge. Rather, it turns on general claims about (1) parents' obligations to help promote their children's well-being and (2) the connection between a person's well-being and the satisfaction of what I call their "worthwhile significant subjective interests." To put this view (too) simply, the fact that a donor-conceived person-who knows she is donor-conceived-is likely to be very interested in acquiring genetic knowledge gives prospective parents a weighty reason to use an identity-release donor. This is because parents should promote their children's well-being through the satisfaction of their children's worthwhile significant interests.

New York State Creates New Governance of Commercial Gestational Surrogacy

United States law recognizes adult reproductive liberty and many states view surrogacy services through that lens. During the COVID-19 pandemic in March, 2020, New York State enacted the Child-Parent Surrogacy Act (CPSA) into law, after feminists and their allies had caused its defeat in 2019. Just before approval of the CPSA, a group of legislators introduced the Alternative Surrogacy Bill (ASB). This article is a case study that examines how the CPSA and not the ASB became law, examining surrogate rights, the best interests of the child, and the ethical issues related to adult donor-conceived and surrogacy born children's rights to information about their ancestry.

Estimates of donated sperm use in the United States: National Survey of Family Growth 1995-2017

OBJECTIVE

To provide national estimates of donor insemination (DI) use in the United States and a description of the population of users.

DESIGN

Population estimates were generated from nationally representative data through weighted proportions and count estimates.

SETTING

Not applicable.

PATIENT(S)

Participants were U.S. women of childbearing age (15-44 years) sampled for interview in the National Survey of Family Growth.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Respondents who reported having received artificial insemination were asked the origin of the sperm. Responses could include husband/partner, donor only, or mixed donor and husband/partner.

RESULT(S)

In 1995, an estimated 170,701 (95% confidence interval 106,577-234,825) women had undergone DI using donor or mixed sperm. In 2015-2017, 440,986 (95% confidence interval 108,458-773,513) women were estimated to have used it. The DI users were mostly white, urban, older, college-educated, and had high family incomes.

CONCLUSION(S)

The DI use changed over time, from a decrease between 1995 and 2013 to a precipitous growth in 2015 to 2017. In recent years, nearly half a million women may be dealing with personal, relationship, and familial issues born of DI use. The United States does not maintain records on the usage of donor sperm, but better tracking of the use and outcomes of treatment would provide better estimates of the size of the affected population.

"I want us to be a normal family": Toward an understanding of the functions of anonymity among U.S. oocyte donors and recipients

BACKGROUND

Anonymity remains the more common practice in gamete donations, but legislation prohibiting anonymity with a goal of protecting donor-conceived children's right to know their genetic origins is becoming more common. However, given the dearth of research investigating the function of anonymity for donors and recipients, it is unclear whether these policies will accomplish their goals. The aim of this study was to explore experiences with anonymity among oocyte donors and recipients who participated in an anonymous donor oocyte program and to understand the ways in which anonymity functions for them.

METHODS

Semistructured interviews were conducted with 50 women: 28 oocyte donors and 22 recipients who were recruited from an academic center for reproductive medicine in the United States.

RESULTS

Donors and recipients view anonymity both as a mechanism to protect the interests of all parties (recipients, donors, and donor-conceived children) and as a point of conflict. Specifically, three key areas were identified where both donors and recipients saw anonymity as having an important role: relieving anxieties about family structures and obligations; protecting their interests and those of donor-conceived children (while acknowledging where interests conflict); and managing the future.

CONCLUSION

As gamete donation increasingly moves away from the practice of anonymity, examining why anonymity matters to stakeholders will be helpful in devising strategies to successfully implement identity-release options.

Soldiers' Preferences Regarding Sperm Preservation, Posthumous Reproduction, and Attributes of a Potential "Posthumous Mother"

We present study results regarding soldiers' willingness to conduct posthumous reproduction. Two hundred twelve Israeli soldiers filled in a questionnaire designed to examine their willingness to cryopreserve sperm and evaluate in which familial circumstances they would consent to posthumous reproduction. They ranked the desirability of 46 attributes of a potential mother and a life partner. Findings indicate a relatively high predisposition in favor of posthumous-assisted reproduction; the wishes of soldiers' parents had much more influence on soldiers' willingness to pursue this technology than those of a partner. Soldiers preferred "feminine" jobs for a potential mother that would allow her to dedicate herself to child-rearing. The desired traits of such a mother were rated similarly to partner preferences; however, significant differences were found in attributes that are most related to the potential mother's devotion to maternity. Interpretations of these findings are contextualized in relation to ethical and bereavement considerations.

The right to know one's genetic origins and cross-border medically assisted reproduction

The use of donor sperm or egg for reproduction raises the issue of the right of donor-conceived individuals to know their genetic origins. This paper argues in favor of acknowledging such a right and explores the challenges that cross-border medically assisted reproduction would raise in relation to it. It first explores possible justifications for such a right by discerning its possible conceptual and empirical groundings. It describes some key ethical and policy implications of the removal of donor anonymity. It then argues that novel technologies such as mitochondrial replacement and gene editing raise new concerns in this area and may expand the scope of such a right. Finally, it argues that while many barriers to accessing information about genetic origins already exist at national levels, cross-border medically assisted reproduction may exacerbate a reality in which many individuals conceived through third-party participation are deprived of information that may be crucial to their future well-being for medical or psycho-social reasons.

How best to protect the vital interests of donor-conceived individuals: prohibiting or mandating anonymity in gamete donations?

Anonymous gamete donation continues to be practised in most jurisdictions around the world, but this practice has come under increased scrutiny. Thus, several countries now mandate that donors be identifiable to their genetic offspring. Critics contend that anonymous gamete donation harms the interests of donor-conceived individuals and that protection of these interests calls for legal prohibition of anonymous donations. Among the vital interests that critics claim are thwarted by anonymous donation are an interest in having a strong family relationship, health interests, and an interest in forming a healthy identity. This article discusses each of these interests and examines what they could involve. The legislation in two countries is considered: Spain, which mandates anonymous gamete donation, and the UK, which prohibits such practice, to assess how these different legislations might or might not protect these vital interests.

Donor insemination: Israel as a representative case of a competitive market examining the possibility of policy reform

AIM

To measure the private and social benefits of donor insemination (DI).

METHODS

An empirical model investigates the general public and DI clients' willingness to pay (WTP) for DI, and the willingness of potential donors to become altruistic or paid sperm donors.

RESULTS

The general public and DI clients value DI and have a positive WTP for it, whereas willingness to donate, altruistically or for payment, is either low or very low.

CONCLUSION

The general public's and DI clients' WTP for DI is in average above actual cost, so the government should consider funding or subsidizing DI. The government should encourage altruistic gamete donation through information and education of all parties involved directly and indirectly in the process of donation whose ultimate goal is the birth of a child.

Mitochondrial donation and 'the right to know'

In this paper, I examine two key arguments advanced by the Human Fertilization and Embryology Authority (HFEA) and the Nuffield Council justifying anonymous mitochondrial donation, even though the 'right to know' is recognised in standard gamete donation. I argue that the two arguments they offer, what I call the argument from genetic connection and the argument from personal characteristics, are unsuccessful. However, I provide additional reasons for why recognising the right to know in gamete donation but not in mitochondrial donation may be justified. I further argue that the status quo in the UK, which is to not recognise a right to know in mitochondrial donation, is provisionally acceptable.

Donor Conception Disclosure: Directive or Non-Directive Counselling?

It is widely agreed among health professionals that couples using donor insemination should be offered counselling on the topic of donor conception disclosure. However, it is clear from the literature that there has long been a lack of agreement about which counselling approach should be used in this case: a directive or a non-directive approach. In this paper we investigate which approach is ethically justifiable by balancing the two underlying principles of autonomy (non-directive approach) and beneficence (directive approach). To overrule one principle in favour of another, six conditions should be fulfilled. We analyse the arguments in favour of the beneficence principle, and consequently, a directive approach. This analysis shows that two conditions are not met; the principle of autonomy should not be overridden. Therefore, at this moment, a directive counselling approach on donor conception disclosure cannot be ethically justified.

Italian law on medically assisted reproduction: do women's autonomy and health matter?

Background

In Italy in 2004, a very restrictive law was passed on medically assisted reproduction (MAR) (Law 40/2004) that placed Italy at the most conservative end of the European spectrum. The law was widely criticized and many couples seeking MAR brought their cases before the Italian Civil Courts with regard to pre-implantation genetic diagnosis (PGD), donor insemination and the issue of consent. Ten years on, having suffered the blows of the Italian Constitutional Court, little remains of law 40/2004.

Discussion

In 2009, the Constitutional Court declared the maximum limit of the number of embryos to be produced and transferred for each cycle (i.e. three), as stated in the original version of the law, to be constitutionally illegitimate. In 2014, the same Court declared as unconstitutional the ban on donor insemination, thus opening the way to heterologous assisted reproduction. Heterologous MAR is therefore perfectly legitimate in Italy. Finally, in 2015 a further ruling by the Constitutional Court granted the right to access MAR to couples who are fertile but carriers of genetic diseases. However, there is still much room for criticism. Many couples and groups are still, in fact, excluded from MAR. Same-sex couples, single women and those of advanced reproductive age are, at the present time, discriminated against in that Italian law denies these subjects access to MAR.

Summary

The history of Law 40/2004 has been a particularly troubled one. Numerous rulings have, over the years, dismantled much of a law constructed in violation of the rights and autonomy of women and couples. However, a number of troubling issues still exist from what is left of the law and the debate is still open at national and transnational level regarding some of the contradictions and gaps in the law highlighted in this article. Only by abolishing the final prohibitions and adopting more liberal views on these controversial yet crucial issues will Law 40/2004 become what it should have been from the start, i.e. a law which outlines the ‘rules of use’ of MAR and not, as it has been until now, a law of bans which sets limits to the freedom to reproduce.

Emerging models for facilitating contact between people genetically related through donor conception: a preliminary analysis and discussion

Previous research indicates interest among some donor-conceived people, donors and recipient parents in having contact. Outcomes of such contact appear largely, but not universally, positive. This paper seeks to understand better the characteristics of associated support services. Information gathered using the authors' direct experiences and professional and personal networks in different parts of the world indicates the emergence of four main groupings: (i) publically funded services outside of treatment centers; (ii) services provided by fertility treatment or gamete bank services; (iii) services provided privately by independent psychosocial or legal practitioners; and (4) services organized by offspring and/or recipient parents. Key operational features examined were: (i) who can access such services and when; (ii) what professional standards and funding are in place to provide them; and (iii) how 'matching' and contact processes are managed. Differences appear influenced variously by the needs of those directly affected, local policies, national legislation and the interests of the fertility services which recruit gamete donors and/or deliver donor conception treatments. The paper is intended to inform fuller debate about how best to meet the needs of those seeking information and contact, the implications for the way that fertility treatment and gametes donation services are currently provided and future research needs.

Regulating Gamete Donation in the U.S.: Ethical, Legal and Social Implications

This article explores the practice of gamete donation in the U.S. having in mind the larger question of what do we as a society owe children born as a result (donor-conceived children). Do recipient-parents have a duty to tell their donor-conceived child about his/her genetic origins? Should the identity of the donor be disclosed or remain anonymous? Does the child have a right to know her conception story and to receive information, including identifying information, about the donor? Furthermore, if a donor-conceived child has a right to know, who has the duty to tell her/him about it? The Article underscores the ethical, legal and social dilemmas that arise, comparing and contrasting with international developments in this arena. It highlights the market-based and more specific medical justifications for regulating this field, explores the emerging so-called right of the child to know his/her genetic origins (“the right to know”), and considers the challenges such a right evokes to existing legal culture and principles of medical ethics in the U.S. as well as other broader societal implications of such a right.

Incidental findings of nonparentage: a case for universal nondisclosure

We advocate for the incorporation of a new clause into the consent forms for pediatric genetic testing that clearly states that any incidental information about parentage will not be revealed, regardless of the result. Using a case of misattributed maternity, we examine both the pro- and antidisclosure arguments. In the absence of arguments that clearly demonstrate irrevocable harm from nondisclosure and against a backdrop of arguments that compellingly highlight the potential for serious harms from disclosing incidental findings of nonparentage, we advocate for a universal, institution-wide policy of nondisclosure. Our proposed policy of universal nondisclosure not only provides a viable solution to the disclosure dilemma but also empowers patients to know what testing is available to them and to seek it out on their own terms, fully informed. With an easily implemented consent change, clinics can take a clear and firm stance in the disclosure debate. As a result, patients will be protected, policy will be widely understood, and cases will be resolved consistently and clearly.

Gamete donors' expectations and experiences of contact with their donor offspring

STUDY QUESTION

What are the expectations and experiences of anonymous gamete donors about contact with their donor offspring?

SUMMARY ANSWER

Rather than consistently wanting to remain distant from their donor offspring, donors' expectations and experiences of contact with donor offspring ranged from none to a close personal relationship.

WHAT IS KNOWN ALREADY

Donor conception is part of assisted reproduction in many countries, but little is known about its continuing influence on gamete donors' lives.

STUDY DESIGN, SIZE, DURATION

A qualitative research model appropriate for understanding participants' views was employed; semi-structured interviews were conducted during January–March 2013.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Before 1998, gamete donors in Victoria, Australia, were subject to evolving legislation that allowed them to remain anonymous or (from 1988) to consent to the release of identifying information. An opportunity to increase knowledge of donors' expectations and experiences of contact with their donor offspring recently arose in Victoria when a recommendation was made to introduce mandatory identification of donors on request from their donor offspring, with retrospective effect. Pre-1998 donors were invited through an advertising campaign to be interviewed about their views, experiences and expectations; 36 sperm donors and 6 egg donors participated.

MAIN RESULTS AND THE ROLE OF CHANCE

This research is unusual in achieving participation by donors who would not normally identify themselves to researchers or government inquiries. Qualitative thematic analysis revealed that most donors did not characterize themselves as parents of their donor offspring. Donors' expectations and experiences of contact with donor offspring ranged from none to a close personal relationship.

LIMITATIONS, REASONS FOR CAUTION

It is not possible to establish whether participants were representative of all pre-1998 donors.

WIDER IMPLICATIONS OF THE FINDINGS

Anonymous donors' needs and desires are not homogeneous; policy and practice should be sensitive and responsive to a wide range of circumstances and preferences. Decisions made to restrict or facilitate contact or the exchange of information have ramifications for donors as well as for donor-conceived people.

STUDY FUNDING/COMPETING INTEREST(S)

The study was funded by the Victorian Department of Health. The authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

Not applicable.

The ethics of anonymous gamete donation: is there a right to know one's genetic origins?

A growing number of jurisdictions hold that gamete donors must be identifiable to the children born with their eggs or sperm, on grounds that being able to know about one's genetic origins is a fundamental moral right. But the argument for that belief has not yet been adequately made.

Proposed legislative change mandating retrospective release of identifying information: consultation with donors and Government response

STUDY QUESTION

How do gamete donors who presumed they could remain anonymous respond to proposed legislation to retrospectively remove anonymity?

SUMMARY ANSWER

A little more than half of the donors opposed the recommendation to introduce legislation to remove donor anonymity with retrospective effect.

WHAT IS KNOWN ALREADY

An increasing proportion of parents disclose their origins to their donor-conceived children and growing numbers of donor-conceived adults are aware of how they were conceived. Research indicates that access to information about the donor is important to donor-conceived people. However, worldwide most donor-conceived people are unable to find any identifying information about the donor because of the practice of anonymous gamete donation.

STUDY DESIGN, SIZE, DURATION

This study adopted a qualitative research model using semi-structured interviews with gamete donors that included open questions. Interviews with 42 volunteers were conducted between December 2012 and February 2013.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Before 1998 gamete donors in Victoria, Australia, were able to remain anonymous. Pre-1998 donors were invited through an advertising campaign to be interviewed about their views on a recommendation that legislation mandating retrospective release of identifying information be introduced.

MAIN RESULTS AND THE ROLE OF CHANCE

Donors were almost evenly split between those who supported and those who rejected the recommendation to introduce legislation to remove donor anonymity with retrospective effect. About half of the donors who rejected the recommendation suggested the compromise of persuading donors voluntarily to release information (whether identifying or non-identifying) to donor-conceived people. These donors were themselves willing to supply information to their donor offspring. The findings of this study informed the Victorian Government's response to the proposed legislative change. While acknowledging donor-conceived people's right of access to information about their donors, the Government decided that identifying information should be released only with the consent of donors and that donors should be encouraged to allow themselves to be identifiable to their donor offspring.

LIMITATIONS, REASONS FOR CAUTION

There is no way of knowing whether participants were representative of all pre-1998 donors.

WIDER IMPLICATIONS OF THE FINDINGS

The balancing of donors' and donor-conceived people's rights requires utmost sensitivity. All over the world, increasing numbers of donor-conceived people are reaching adulthood; of those who are aware of their mode of conception, some are likely to have a strong wish to know the identity of their donors. Legislators and policy-makers in jurisdictions permitting anonymous gamete donations will need to respond when these desires are expressed, and may choose to be guided by the model of consultation described in this paper.

STUDY FUNDING/COMPETING INTERESTS

The study was funded by the Victorian Department of Health. The authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

Not applicable.

The right to know your genetic parents: from open-identity gamete donation to routine paternity testing

Over the years a number of countries have abolished anonymous gamete donation and shifted toward open-identity policies. Donor-conceived children are said to have a fundamental "right to know" the identity of their donor. In this article, we trace the arguments that underlie this claim and question its implications. We argue that, given the status attributed to the right to know one's gamete donor, it would be discriminatory not to extend this right to naturally conceived children with misattributed paternity. One way to facilitate this would be through routine paternity testing at birth. While this proposal is likely to raise concerns about the conflicting interests and rights of other people involved, we show that similar concerns apply to the context of open-identity gamete donation. Unless one can identify a rational basis for treating the two groups differently, one's stance toward both cases should be the same.