The embryo as moral work object: PGD/IVF staff views and experiences

(Not) wanting to choose: outside agencies at work in assisted reproductive technology

Human choice and interventions that could seem to threaten the course of 'nature' or 'chance' are at the heart of controversies over assisted reproductive technology across Western countries. These debates focus predominately on so-called 'selective reproductive technology'. While today, the technique of in-vitro fertilization (IVF) raises few political and bioethical debates in France and other Western countries, concerns remain that human intervention might replace 'natural' processes, threatening human procreation. These polemics focus on situations that require a decision, notably embryo selection and the fate of spare frozen embryos. The choices involved are induced by the technology and organized by the law. In the French legal system, IVF patients and professionals have the opportunity and, to a certain extent, the responsibility to decide on the status of in-vitro embryos. This article shows that, in these situations, both IVF patients and professionals invoke outside agencies ('instances tierces'), both to avoid making decisions and to recover a world order in which procreation is not entirely subject to human decision. In short, there is a need to feel that procreation is not entirely dependent on human intervention; that individuals do not decide everything. It appears that the choices that are made, their nature and the type of outside agency that is invoked are highly situated.

Excluding indigenous bioethical concerns when regulating frozen embryo storage: An Aotearoa New Zealand case study

This article undertakes a close reading of the parliamentary debates associated with the topic of embryo cryopreservation in Aotearoa New Zealand. From our critical readings, we argue that there is a lack of transparency over the ethical reasons for enforcing a maximum storage limit. We demonstrate that arguments for the retention of this limit are associated (in New Zealand) with arguments based upon 'build-up avoidance' and 'conflict avoidance' as social goods based on Pākehā [New Zealander of European descent] cultural world views rather than identifiable universal ethical principles. We illustrate that the avoidance of embryo accumulation and related conflict was only achieved by the denial of indigenous spiritual and cultural concerns, while also shifting the ethical burdens of disposition on to clinic staff and those members of the public who protested against enforced cryopreserved embryo disposal. The Pākehā cultural concept of 'tidy housekeeping' emerges as a presumed ethical and social good in the New Zealand situation. This is despite abundant literature documenting the suffering created through forced decision-making upon disposition.

Religious Scholars' Attitudes and Views on Ethical Issues Pertaining to Pre-Implantation Genetic Diagnosis (PGD) in Malaysia

Pre-Implantation Genetic Diagnosis (PGD) represents the first fusion of genomics and assisted reproduction and the first reproductive technology that allows prospective parents to screen and select the genetic characteristics of their potential offspring. However, for some, the idea that we can intervene in the mechanisms of human existence at such a fundamental level can be, at a minimum, worrying and, at most, repugnant. Religious doctrines particularly are likely to collide with the rapidly advancing capability for science to make such interventions. This paper focuses on opinions and arguments of selected religious scholars regarding ethical issues pertaining to PGD. In-depth interviews were conducted with religious scholars from three different religious organizations in the Klang Valley, Malaysia. Findings showed that Christian scholars are very sceptical of the long-term use of PGD because of its possible effect on the value of humanity and the parent-children relationship. This differs from Islamic scholars, who view PGD as God-given knowledge in medical science to further help humans understand medical genetics. For Buddhist scholars, PGD is considered to be new medical technology that can be used to save lives, avoid suffering, and bring happiness to those who need it. Our results suggest that it is important to include the opinions and views of religious scholars when it comes to new medical technologies such as PGD, as their opinions will have a significant impact on people from various faiths, particularly in a multi-religious country like Malaysia where society places high value on marital relationships and on the traditional concepts of family.

Religious beliefs, knowledge about science and attitudes towards medical genetics

The use of genetics in medical research is one of the most important avenues currently being explored to enhance human health. For some, the idea that we can intervene in the mechanisms of human existence at such a fundamental level can be at minimum worrying and at most repugnant. In particular, religious doctrines are likely to collide with the rapidly advancing capability for science to make such interventions. The key ingredient for acceptance of genetics, on the other hand, is prototypically assumed to be scientific literacy - familiarity and understanding of the critical facts and methods of science. However, this binary opposition between science and religion runs counter to what is often found in practice. In this paper, we examine the association between religiosity, science knowledge and attitudes to medical genetics amongst the British public. In particular, we test the hypothesis that religion acts as a 'perceptual filter' through which citizens acquire and use scientific knowledge in the formation of attitudes towards medical genetics in various ways.

L’embryon humain en AMP, éléments pour une approche relationnelle

L’analyse socio-anthropologique de la parenté en assistance médicale à la procréation (AMP) présuppose, qu’on le sache ou non, de donner un certain statut à l’embryon. Cependant, ce statut reste encore largement un point aveugle du débat des sciences sociales. L’anthropologie a beaucoup analysé la façon dont les techniques, et en particulier l’échographie, ont contribué à l’image de l’embryon comme « isolat », séparé en particulier du corps féminin dans lequel il était autrefois enclos et enfoui (Strathern, 1992). L’AMP, avec la congélation et la fécondation in vitro, a encore accentué cette représentation. Cependant, l’observation ethnographique des pratiques d’AMP révèle que l’embryon est en réalité toujours pris dans des réseaux relationnels (Thompson, 2005). Relations, d’une part, à des professionnels qui ont à un certain moment, du fait de leur statut, le pouvoir de sélectionner, détruire ou conserver cet embryon. D’autre part, et surtout, en référence à la parenté, à l’ensemble des personnes impliquées dans la procréation, l’engendrement ou la filiation, et qui de ce fait ont elles aussi un ensemble de pouvoirs et de devoirs à l’égard de cet embryon. Cet article s’appuie sur une enquête par entretiens semi-directifs auprès de 70 professionnels de l’AMP et a pour objectif d’analyser l’embryon en AMP grâce à une approche relationnelle inspirée de l’héritage maussien en matière d’analyse du genre et de la parenté (Théry, 2007). Cette approche permet de décrire autrement la scène de l’AMP et de comprendre comment l’embryon alterne entre diverses positions – entre enfant potentiel et pur matériau organique – selon le système de relations instituées dans lequel il se trouve inscrit. Notre hypothèse est qu’une telle approche éclaire de façons nouvelles les dilemmes parfois aigus des « parents » confrontés à l’embryon congelé hors projet et aux quatre grandes options prévues par la loi française : garder, donner à la recherche, « donner » à un autre couple ou détruire.

When biological scientists become health-care workers: emotional labour in embryology

STUDY QUESTION

Can biological scientists working in medically assisted reproduction (MAR) have a role as health-care workers and, if so, how do they engage in the emotional labour commonly associated with health-care work?

SUMMARY ANSWER

The scientists at Fertility Associates (FA) in New Zealand perform the technical and emotional cares associated with health-care work in an occupationally specific manner, which we refer to as a hybrid care style. Their emotional labour consists of managing difficult patients, 'talking up' bad news, finding strategies to sustain hope and meaning, and 'clicking' or 'not clicking' with individual patients.

WHAT IS KNOWN ALREADY

Effective emotional labour is a key component of patient-centred care and is as important to the experience of high-quality MAR as excellent clinical and scientific technique.

STUDY DESIGN, SIZE, DURATION

This is a qualitative study based on open-ended interviews and ethnographic observations with 14 staff in 2 laboratories conducted over 2 separate periods of 3 weeks duration in 2007. Analysis of fieldnotes and interviews was conducted using thematic analysis and an NVivo qualitative database and compared for consistency across each interviewer.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The participants were consenting biological scientists working in one of the two laboratories. Semi-structured interviews were conducted in 'quiet' work times, and supervised access was allowed to all parts of the laboratories and meeting places. Opportunities for participant review of results and cross comparison of independent analysis by authors increases the faithfulness of fit of this account to laboratory life.

MAIN RESULTS AND THE ROLE OF CHANCE

The study suggests that emotional labour is a part of routinized scientific labour in MAR laboratories for FA.

LIMITATIONS, REASONS FOR CAUTION

This is a qualitative study and thus the findings are not generalizable to populations beyond the study participants.

WIDER IMPLICATIONS OF THE FINDINGS

While little has been published of the emotional component of scientist's working lives, there may be a New Zealand style of doing scientific work in MAR laboratories which is patient centred and which incorporates much higher patient contact and involvement than is experienced in other laboratories.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by a research grant from the University of Otago and was also partly funded by a Marsden Grant administered by the Royal Society of New Zealand.

TRIAL REGISTRATION NUMBER

N/A.

Body work in assisted conception: exploring public and private settings

Body work has been foregrounded in recent sociological writings on health and social care, particularly the emotional labour of patient care. In this article I explore the social and emotional dimensions of body work in assisted conception in private and public National Health Service (NHS) clinics. Drawing on an ethnographic study, I explore how tensions around bodily attributes, treatment costs, clinic performance and the extent of consumer sovereignty were managed in decisions about who to treat and in what manner. In NHS settings, body work involved efforts to standardise and constrain bodies in line with an ethics of justice that included the co-construction of protocols and performance measurement and a strong emphasis upon teamwork and influencing the behaviour of the sector as a whole. In contrast, body work in private settings was more overtly organised around an ethos of individual consumption that emphasised bespoke treatment together with an active critique of the regulator, based on a strong entrepreneurial ethos. Emotional labour in private settings was also more overt. I conclude by exploring the implications of my analysis for the study of assisted conception, the sociology of body work and the further marketisation and deregulation of medicine.

Embryo futures and stem cell research: the management of informed uncertainty

In the social worlds of assisted conception and stem cell science, uncertainties proliferate and particular framings of the future may be highly strategic. In this article we explore meanings and articulations of the future using data from our study of ethical and social issues implicated by the donation of embryos to human embryonic stem cell research in three linked assisted conception units and stem cell laboratories in the UK. Framings of the future in this field inform the professional management of uncertainty and we explore some of the tensions this involves in practice. The bifurcation of choices for donating embryos into accepting informed uncertainty or not donating at all was identified through the research process of interviews and ethics discussion groups. Professional staff accounts in this study contained moral orientations that valued ideas such as engendering patient trust by offering full information, the sense of collective ownership of the National Heath Service and publicly funded science and ideas for how donors might be able to give restricted consent as a third option.

Fresh or frozen? Classifying 'spare' embryos for donation to human embryonic stem cell research

United Kingdom (UK) funding to build human embryonic stem cell (hESC) derivation labs within assisted conception units (ACU) was intended to facilitate the ‘In-vitro fertilisation (IVF)-stem cell interface’, including the flow of fresh ‘spare’ embryos to stem cell labs. However, in the three sites reported on here, which received this funding, most of the embryos used for hESC research came from long term cryopreservation storage and/or outside clinics. In this paper we explore some of the clinical, technical, social and ethical factors that might help to explain this situation. We report from our qualitative study of the ethical frameworks for approaching women/couples for donation of embryos to stem cell research. Members of staff took part in 44 interviews and six ethics discussion groups held at our study sites between February 2008 and October 2009. We focus here on their articulations of social and ethical, as well as scientific, dimensions in the contingent classification of ‘spare’ embryos, entailing uncertainty, fluidity and naturalisation in classifying work. Social and ethical factors include acknowledging and responding to uncertainty in classifying embryos; retaining ‘fluidity’ in the grading system to give embryos ‘every chance’; tensions between standardisation and variation in enacting a ‘fair’ grading system; enhancement of patient choice and control, and prevention of regret; and incorporation of patients’ values in construction of ethically acceptable embryo ‘spareness’ (‘frozen’ embryos, and embryos determined through preimplantation genetic diagnosis (PGD) to be genetically ‘affected’). We argue that the success of the ‘built moral environment’ of ACU with adjoining stem cell laboratories building projects intended to facilitate the ‘IVF-stem cell interface’ may depend not only on architecture, but also on the part such social and ethical factors play in configuration of embryos as particular kinds of moral work objects.

Consenting futures: professional views on social, clinical and ethical aspects of information feedback to embryo donors in human embryonic stem cell research

This paper reports from an ongoing multidisciplinary, ethnographic study that is exploring the views, values and practices (the ethical frameworks) drawn on by professional staff in assisted conception units and stem cell laboratories in relation to embryo donation for research purposes, particularly human embryonic stem cell (hESC) research, in the UK. We focus here on the connection between possible incidental findings and the circumstances in which embryos are donated for hESC research, and report some of the uncertainties and dilemmas of our staff participants. We explore the views of our study participants in relation to two themes: (1) rights to information and anticipating how donors might be informed about future research findings and (2) occupational work goals and trust.

A 'healthy baby': The double imperative of preimplantation genetic diagnosis

This article reports from a study exploring the social processes, meanings and institutions that frame and produce 'ethical problems' and clinical dilemmas for practitioners, scientists and others working in the specialty of preimplantation genetic diagnosis (PGD). A major topic in the data was that, in contrast to IVF, the aim of PGD is to transfer to the woman's womb only those embryos likely to be unaffected by serious genetic disorders; that is, to produce 'healthy babies'. Staff described the complex processes through which embryos in each treatment cycle must meet a double imperative: they must be judged viable by embryologists and 'unaffected' by geneticists. In this article, we focus on some of the ethical, social and occupational issues for staff ensuing from PGD's double imperative.

Opinions concerning pre-implantation genetic diagnosis and sex selection among gynecologist-obstetricians in Brazil

OBJECTIVE

The aim of this study was to assess a sample of obstetrician-gynecologists on their technical knowledge of PGD as well as their views of PGD and sex selection (SS).

STUDY DESIGN

Cross-sectional observational study, carried out during a Congress on Gynecology and Obstetrics. A self-report questionnaire was offered to all professionals registered to attend the Congress and answers of 723 physicians were analyzed.

RESULTS

Of the participants, 436 (60.3%) were female and 287 (39.7%) were male; 517 (71.5%) had children. Regarding knowledge of PGD techniques, 63.2% had heard something about PGD and/or preconception SS. Concerning SS, physicians believed that SS is always the couple's choice (36.4%), should be the couple's choice only in specific situations (42.6%), or did not agree that SS should be a couple's choice (17.4%). A majority of the respondents were in favor of PGD and believed that pre-embryos with 6-8 cells are human life in potency.

CONCLUSIONS

In spite of a small percentage of gynecologists-obstetricians in Brazil had knowledge of PGD techniques, many of them recognized it to be a method to prevent genetic diseases and agreed with its use. The SS appears to be highly accepted for use in specific situations.

Testing the embryo, testing the fetus

This paper stems from an ethnographic, multidisciplinary study that explored the views and experiences of practitioners and scientists on social, ethical and clinical dilemmas encountered when working in the area of PGD for serious genetic disorders. We focus here on staff perceptions and experiences of working with embryos and helping women/couples to make choices that will result in selecting embryos for transfer and disposal of 'affected' embryos, compared to the termination of affected pregnancies following PND. Analysis and discussion of our data led us to consider the possible advantages of PGD and whether a gradualist account of the embryo's and fetus's moral status can account for all of these, particularly since a gradualist account concentrates on the significance of time (developmental stage) and makes no comment as to the significance of place (in-vitro, in-utero).