1. Introduction
1.1 The Adelaide Hospital Society appreciates this opportunity to make a Submission to the Commission on Assisted Human Reproduction. Given the time available for the preparation and consideration of this Submission, the Society has focused upon the principles and approaches which it believes will be helpful to the Commission in its work.
The Society will be glad to expand upon this Submission with the Commission should this be found helpful.
1.2 Assisted Human Reproduction: an essential health service
Since the birth of Louise Brown on 25th July, 1978, the use of in-vitro fertilisation (IVF) has become widespread, taking place alongside the already longer established procedures of artificial insemination (AI).
Many thousands of children have been born through assisted human reproduction (AHR) and this represents an enormous positive advance in respect of the problems associated with infertility.
AHR is now part of normal medicine and ought to be provided as an essential and standard service by our public health services for all who need to avail of AHR regardless of financial means.
1.3 The Adelaide Hospital Society recognises and acknowledges the pioneering efforts of another public voluntary teaching hospital, the Rotunda Hospital, under Dr R. Harrison, to provide access to AHR and to seek to ensure that AHR becomes a normal mainstream service available without financial barriers to public patients.
For having children is so fundamental a need for human beings that such a service may indeed be described as contributing to the development of a contented society in which the well-being of all people is of foremost concern.
It is essential that basic clinical services in respect of infertility should be provided to a high quality throughout Ireland and this should provide the context for AHR services for public patients. Each Health Board or Authority should have the responsibility of ensuring that AHR services are available to the citizens it serves either within its own area or outside its area.
1.4 The situation of people who suffer the consequences of infertility deserves more attention in our society.
The conditions and living patterns of modern society may be giving rise to increased incidence of infertility. There are often very negative consequences for couples who are infertile and assisted human reproduction may resolve these consequences and therefore, it is to be welcomed.
The Adelaide Hospital Society welcomes the establishment of the Commission on Assisted Human Reproduction and is pleased at this opportunity to submit a brief outline of its views to the Commission.
1.5 We recognise that the issues before the Commission go beyond those arising from infertility. For example there are commercial interests, often with powerful financial motivations, at work providing services. This is a further reason why the issues should not be avoided in our public health services.
1.6 The Adelaide Hospital Society in this outline Submission sets out a framework of principles which might govern subsequent detailed regulations and we propose a structure (The Permanent Commission on Assisted Human Reproduction, see below para. 5.1) to oversee assisted human reproduction practices in the future.
1.7 The Adelaide Hospital Society believes that AHR relates to matters which are essentially private and of great delicacy. Therefore, the State has to be very careful about intrusion in these matters where confidentiality and privacy are of vital concern.
AHR involves matters for discussion between doctors and patients which must be private and confidential and there should be no direct State or external interference in the treatment of particular cases where the approach ought to be as inclusive as possible for all our citizens.
However, both the public and patients generally require to have confidence in all the services provided and for this reason the Permanent Commission as recommended in para. 5.1 below should have regulatory and other responsibilities.
(Sections 2, 3 and 4 have been omitted)
5 - Structures for the Way Forward: A Permanent Commission
5.1 The Adelaide Hospital Society believes that the Government should introduce enabling legislation to establish a broadly based representative Permanent Commission on Assisted Human Reproduction which would have the power, under statute, to regulate from time to time practices in respect of any aspect of assisted human reproduction.
5.2 We do not believe it would be practicably possible to legislate successfully for the detail of every particular circumstance now arising or likely to arise in relation to AHR and such an approach should be avoided.
The approach we suggest in 5.1 above will provide a statutory framework for the control and supervision of research involving human embryos and will provide for the licensing of certain types of AHR practices.
5.3 The Permanent Commission should be widely representative and have the confidence of the professions and public at large. The majority of the members should be women and lay people.
We endorse the approach recommended in this matter recommended by the Warnock Report in 1984 in respect of the Human Fertilisation and Embryology Authority in the United Kingdom:
". . . this is not exclusively, or even primarily, a medical or scientific body. It is concerned essential with broader matters and with the protection of the public interest.
If the public is to have confidence that this is an independent body, which is not to be unduly influenced by sectional interests, its membership must be wide-ranging and in particular the lay interests should be well represented . . . \he chairman must be a lay person. Report of the Committee of Enquiry into Human Fertilisation and Embryology \The Warnock Report\ HMSO, London, 1984 p.76
5.4 The Permanent Commission would be the licensing authority for specified practices associated with AHR. The terms of reference of the Permanent Commission would give it responsibilities for continuing public deliberation and ensuring widespread consultation in respect of developments in AHR.
The Permanent Commission would have authority to accredit providers in accord with standards and would be able to provide advice in respect of relevant aspects of the health services. It would also have powers to control any breaches of regulations or malpractice in respect of AHR.
6 - Adelaide Hospital Society responses to the issues listed as relevant by the Commission
6.1 Legislation or reliance on medical ethics?
The Adelaide Hospital Society recommends a relatively straightforward piece of legislation. The purpose would be to establish a Permanent Commission on Assisted Human Reproduction as described in 5.1 above. The work of the Commission would be much wider than medical ethical guidelines and it would have an overall regulatory function of a permanent ongoing kind.
6.2 Replacement or freezing of embryos
For new reproductive technologies to advance, it is essential for research to be undertaken on embryos. Ireland benefits from such research and applies the results of that research in assisted human reproduction procedures.
Freezing and storing of surplus embryos is a proper practice under regulated and licensed medical procedures. There are obvious advantages to women's health in respect of a freezing programme. It is the responsibility of the mother or partner, in consultation with their doctor, to decide the future of surplus embryos.
The further issues which arise from the availability of freezing, including research (see below para 6.10) are matters for detailed and ongoing regulation by the Permanent Commission rather than by legislation. It is unlikely that such detailed issues can be satisfactorily supervised by legislation.
6.3 The Unborn
The use of the adjective "unborn" in our Constitution is most unsatisfactory. We are not aware that it has any scientific meaning. It is imperative that the Commission envisages the development of a human person as a process and that the legal and moral implications must evolve and increase as that development occurs.
6.4 Status of the person
Issues concerning the status of the person deriving from approved assisted human reproduction practices are matters for detailed regulation (and ought to be subject to revision from time to time in the light of experience) by the Permanent Commission recommended above in para. 5.1.
The respect due to human embryos is clear, but it is different in kind and character to that due to the foetus and to that due to the human person who is alive after birth.
6.5 Freezing of sperm or ova
In principle, the freezing of sperm or ova should be permitted under regulated conditions by the Permanent Commission.
6.6 Artificial insemination by donor
The Adelaide Hospital Society believes that in general assisted human reproduction practices should be subject to strict control and based upon clear medical indication of infertility and social need as defined by regulation.
6.7 Restrictions on who may avail of the services
There is a need to regulate availability of the services in the interests of the children who may be born as a result of them. There should be a professional assessment of the stability of the relationships involved. Such an assessment should be sensitive and confidential and take into account the changing nature of the family in society.
6.8 Donor programmes and surrogacy
The Adelaide Hospital Society believes that there is an important and positive place for donor programmes in AHR. The Adelaide Hospital Society favours strictly controlled donor programmes. It recognises the complexity of surrogacy in legal and social terms and we note that this presented the Warnock Committee with some of the most difficult problems it encountered.
6.9 Screening of embryos for genetic conditions
The Adelaide Hospital Society believes that parents are entitled to the fullest possible information in respect of the genetic conditions affecting their children and that screening, under regulated conditions, is necessary to obtain such information.
6.10 Research on embryos
It is now widely accepted internationally that research on very early human embryos (up to 14 days) may be of considerable medical value as, for example, in relevant stem cell research. Research on embryos to the 14-day stage only should be permissible on the basis of best practice and under strict licensing and control from the Permanent Commission recommended above at para. 5.1.
6.11 Cloning
The Adelaide Hospital Society believes that human cloning for reproducing the human person should be prohibited
7 - Conclusion: A Caring Vision
7.1 The Adelaide Hospital Society believes that a new caring vision is vital for our health services and indeed for Irish society as a whole. It is within this context that AHR ought to be addressed in public policy.
We should seek to develop collectively a new vision which would understand and take seriously the pain and suffering of infertility. We need to find the causes of the increase of infertility and to seek to tackle them.
We need a new caring vision to ensure the availability of public health services and community support networks, and in particular infertility counselling, to help women and men to come to terms with the sadness and loss of involuntary childlessness.