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The American Journal of Bioethics 3.1 (2003) 41-43



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HIV and Assisted Reproductive Technology:
Women and Healthcare Policy

Anne Drapkin Lyerly
Duke University

Ruth R. Faden
Johns Hopkins University

From the time that perinatal transmission of human immunodeficiency virus (HIV) was first identified as a major cause of pediatric acquired immune deficiency syndrome (AIDS), prevailing public opinion marginalized HIV-seropositive women who became pregnant intentionally or unintentionally. In 1996 a multidisciplinary working group on HIV and reproduction considered emerging policies aimed at limiting the reproductive choices of HIV-seropositive women and recommended, instead, "contextualized counseling toward reasoned and reflective decisions about childbearing" (Faden and Kass 1996). Nevertheless, until very recently, most major medical societies supported the exclusion of HIV-seropositive individuals from assisted reproductive services (Ethics Committee of the American Fertility Society 1994).

With recent advances in the prognosis of HIV-seropositive individuals and a dramatic decrease in the risk of vertical transmission, we and others have called into question policies categorically excluding HIV-seropositive individuals from assisted reproductive services (Lyerly and Anderson 2001; Minkoff and Santoro 2000; Ethics Committee of the American Society for Reproductive Medicine 2002). In light of these arguments, the establishment of a program to provide intracytoplasmic sperm injection (ICSI) to HIV-serodiscordant couples in which the male partner is seropositive, as reported by Mark V. Sauer (2003), represents an important step toward just healthcare policy regarding the reproductive rights of HIV-seropositive individuals. However, Columbia Presbyterian's policy remains embedded in the tradition that marginalized HIV-seropositive and potentially seropositive women considering pregnancy, and raises at least two issues specific to women and their reproductive choices. First, the continued exclusion of HIV-seropositive women from assisted reproductive services is ethically unjustifiable. Second, given data from Europe, the decision to expose otherwise fertile partners of HIV-seropositive men to the risks of ovarian stimulation and retrieval, instead of the lesser risks of intrauterine insemination, is ethically problematic.

HIV-Seropositive Women:
Unjustified Exclusion

The assisted reproductive techniques employed by Sauer were applied exclusively to serodiscordant couples in which the male partner was HIV-seropositive. According to Sauer, "the Ethics Committee of Columbia Presbyterian Medical Center failed to endorse protocols related to HIV seropositive women." This policy was apparently based on continued concerns about vertical transmission of HIV and viral contamination of other tissue cultures in the laboratory. As we have argued elsewhere, these justifications are not morally sound (Lyerly and Anderson 2001). We briefly outline the main points of these arguments below.

Justice requires of medical professionals and policy makers that they treat individuals fairly. One simple formulation of fair treatment, sometimes referred to as the formal principle of justice, requires that similar cases be treated similarly. We are concerned that HIV seropositive women are treated differently than other persons struggling with infertility who are in relevantly similar situations and that the stigma that remains associated with HIV, rather than HIV per se, is the reason that women are not granted assistance. Consider the aspects of HIV that are felt to be a contraindication to assisted reproduction that are similar to the aspects of other medical conditions for which informed decision making, rather than exclusion, is accepted policy.

The major concern raised by Columbia's ethics committee was vertical transmission and thus that children would be born with HIV as a result of reproductive assistance. Indeed, the infection of even one child with HIV has potentially tragic consequences. But justice requires that we consider whether policies to prevent congenital illness unfairly burden a particular class of individuals with a particular disease or disability. There are other similarly devastating, though not identical, congenital conditions that may or may not occur as a result of reproductive assistance. Genetic diseases such as trisomy 18 or 21 (Down's syndrome) are one example. We know that children born with Down syndrome are at increased risk for complicated medical problems such as heart and gastrointestinal defects that can be emotionally and financially devastating for families. The risk of a 39-year-old woman (a...

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