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Play: Scene Are sex and fertilisation ready for divorce?

2006; Elsevier BV; Volume: 368; Linguagem: Inglês

10.1016/s0140-6736(06)69930-3

1474-547X

Carl Djerassi,

Reproductive Health and Technologies

In his famous 1936 essay, The work of art in an age of mechanical reproduction, Walter Benjamin stated: "The technique of reproduction detaches the reproduced object from the domain of tradition." But if "The work of art" is replaced by "Sex" in the title, and "reproduced object" by "offspring" in the quotation, a much deeper issue is illustrated: detachment of the child from traditional procreation may well be the most fundamental ethical issue raised by techniques of assisted reproduction. Neither science nor society has so far adequately prepared us for that consequence of sex in an age of mechanical reproduction. Cast of charactersDr Felix Frankenthaler: middle-aged American clinician and infertility specialist; well dressed, preferably with tie and jacket.Ms Isabel Youngblood: host of TV programme Dissection; middle thirties, politically green and a strong critic of science and technology; stylishly dressed, preferably in trouser suit.LocationTV studio of weekly "issues" programme, Dissection. This evening's topic was "Sex in an age of mechanical reproduction" with emphasis on techniques of assisted reproduction, such as in-vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI).Last scenePersonal discussion between Youngblood and Frankenthaler after the end of a rather contentious TV programme.Frankenthaler Before I leave, may I ask you a question, Ms Youngblood? Do you have children?Youngblood I'm not accustomed to being interviewed by my guests.Frankenthaler We're now off camera. (Pause). Anyway, I take it the answer is "no." Now I won't ask how old you are, but I'd guess middle thirties.Youngblood Dr Frankenthaler, your personal questions have nothing to do with tonight's topic.Frankenthaler I beg to differ. They have a great deal to do with ICSI, because we have not addressed one issue of overwhelming importance. In fact, I'm surprised that you hadn't brought it up yourself during your show.Youngblood And what might that be?Frankenthaler Whether in the future fertile people might also resort to ICSI and other IVF procedures, rather than just those with infertility problems.Youngblood All right. I'll nibble on your bait. Why would normal people—Frankenthaler I didn't say "normal". I said "fertile".Youngblood I stand corrected. So why would fertile people spend thousands of dollars to produce a baby without sexual intercourse, when they can do it without cost and much more pleasurably in the usual way?Frankenthaler Fair enough. But that is why I asked whether you had any children and commented on your age.Youngblood What's my age got to do with it?Frankenthaler For argument's sake, let me assume that you have no children, that you are now 35, and that you do wish to have some children in the future, but not now. If you wait for another 5 years—Youngblood I have now stopped nibbling on your bait.Frankenthaler Relax! I was trying to generalise from a hypothetical Isabel Youngblood. Given that hypothetical age, just postponing childbearing from 35 to 40 years of age would at least quadruple your chances of giving birth to a baby with Down's syndrome.Youngblood I'm fully aware of that. It is one of the reasons why many pregnant women in that age group undergo amniocentesis.Frankenthaler Of course. But why? Because they are prepared to consider an abortion to terminate such a pregnancy if an extra chromosome is discovered during the testing. But as we discussed earlier in your programme, with ICSI, several embryos are available—Youngblood Sure. But for that, the woman would first have to undergo a course of hormone-induced superovulation to generate a supply of eggs. By no means a trivial procedure.Frankenthaler Yet something that millions of women have done—Youngblood Because they suffered from infertility problems, and IVF was their only option. I thought we were talking about fertile women?Frankenthaler So we are: about fertile women, who do not necessarily wish to wait for the third month of pregnancy to take the amniocentesis and potential abortion route. Such women could select preimplantation genetic diagnosis: looking for the same genetic markers as in prenatal testing, but doing so with a 3-day-old embryo before transfer into the uterus. Given such a scenario, she would simply discard the defective embryo and use another one. As I already pointed out during the programme, we are then not talking about abortion but selective reduction of the risk. For many women, especially those who do not consider a 3-day-old embryo in a petri dish a baby, this is not just a semantic quibble, because they might feel differently about a 3-month-old fetus in the uterus. And as more and more professional women postpone childbearing to that more dangerous age, some will also consider their access to preimplantation genetic diagnosis a sufficient incentive to undergo superovulation.Youngblood And that will cause millions of older women—Frankenthaler Just call them mature women.Youngblood Whatever! To stand in line at ICSI clinics to get their babies?Frankenthaler I didn't say millions. I don't know how many, but I believe the number will surprise all of us, at least in the affluent countries, notably in Europe and perhaps also Japan, where the average number of children is below 1·5 per family. And, of course, in the USA. It's an option they should not be denied. Especially because the rapid advances in genomics will allow us also to screen for certain other genetic markers—say a high predisposition to certain cancers.Youngblood And where will that stop, once we start looking for genetic markers? First one marker, then several, and then lots of markers? What kind of slippery slope are we then following?Frankenthaler In time, it may become quite slippery. Another reason why this topic ought to be discussed and debated. But making it illegal is unlikely to work, other than stimulating medical tourism, with its inherent discrimination in favour of the wealthy who can afford to indulge in such luxury.Youngblood So it's the possibility of preimplantation genetic diagnosis that will drive fertile women to consider IVF?Frankenthaler That might be the reason now, today, without further technical advances. But consider the fact that we now know how to store sperm and embryos for years—Youngblood (Laughs) And "cryopreservation" will become such a standard word that even cooks will talk about "cryopreservation" of food in the kitchen?Frankenthaler Think about the day, when we shall know how to store eggs or ovarian tissue in that way, a scenario we already discussed. It's almost here. I'd give it another decade or two and it will start becoming routine.Youngblood And?Frankenthaler And then offer young—not just mature—women the choice to undergo superovulation in their early twenties, when the quality of their eggs is far superior to those in their middle or late thirties.Youngblood And store their young eggs for eventual use by IVF years later?Frankenthaler As a reproductive insurance policy—for young women embarking on ambitious careers, who are not prepared to choose that early between motherhood and career—why not?Youngblood With their eggs in the bank, they might as well then get sterilised at that young age rather than practise contraception, and just check out an egg when they're ready for motherhood. Is that it? The end of the Pill and other contraceptives?Frankenthaler I'm sure that some will do that.Youngblood And why not men?Frankenthaler And men, of course. Especially since the technical difficulties of cryopreserving sperm for years or even decades have already been solved.Youngblood And you think that's good?Frankenthaler It's neither good nor bad. It's an option that should be available to those women, and men, who wish to exercise it.Youngblood I don't think we are talking science any more—or ICSI.Frankenthaler You're right. We're talking about women's choices—or religion. That's why it's time for me to leave. As a physician, I can present women with technical facts, but not with making the most important decision in their lives. (As he rises.) But would you mind if I offered one last piece of advice?Youngblood That depends on what it is.Frankenthaler Let me propose a theme for one of your future programmes.Youngblood Okay. Let's hear it.Frankenthaler "Are sex and fertilisation ready for divorce?"Youngblood I gather you think they are.Frankenthaler My opinion is not important. I'm talking about future generations, starting with those who right now are in school. They should debate that issue. Because they are the ones who will indulge in sex in an age of mechanical reproduction. Carl Djerassi, Professor of Chemistry Emeritus at Stanford University, is one of the few American scientists to have been awarded both the National Medal of Science (for the first synthesis of a steroid oral contraceptive) as well as the National Medal of Technology. In addition to many other awards, he is the recipient of 20 honorary doctorates (the latest in 2005 from Cambridge University). He is the author of five novels and six plays, two of which (An Immaculate Misconception and Taboos) deal with the ethical and social ramifications of assisted reproductive techniques. In his famous 1936 essay, The work of art in an age of mechanical reproduction, Walter Benjamin stated: "The technique of reproduction detaches the reproduced object from the domain of tradition." But if "The work of art" is replaced by "Sex" in the title, and "reproduced object" by "offspring" in the quotation, a much deeper issue is illustrated: detachment of the child from traditional procreation may well be the most fundamental ethical issue raised by techniques of assisted reproduction. Neither science nor society has so far adequately prepared us for that consequence of sex in an age of mechanical reproduction. Cast of charactersDr Felix Frankenthaler: middle-aged American clinician and infertility specialist; well dressed, preferably with tie and jacket.Ms Isabel Youngblood: host of TV programme Dissection; middle thirties, politically green and a strong critic of science and technology; stylishly dressed, preferably in trouser suit.LocationTV studio of weekly "issues" programme, Dissection. This evening's topic was "Sex in an age of mechanical reproduction" with emphasis on techniques of assisted reproduction, such as in-vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI).Last scenePersonal discussion between Youngblood and Frankenthaler after the end of a rather contentious TV programme. Cast of charactersDr Felix Frankenthaler: middle-aged American clinician and infertility specialist; well dressed, preferably with tie and jacket.Ms Isabel Youngblood: host of TV programme Dissection; middle thirties, politically green and a strong critic of science and technology; stylishly dressed, preferably in trouser suit.LocationTV studio of weekly "issues" programme, Dissection. This evening's topic was "Sex in an age of mechanical reproduction" with emphasis on techniques of assisted reproduction, such as in-vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI).Last scenePersonal discussion between Youngblood and Frankenthaler after the end of a rather contentious TV programme. Cast of characters Dr Felix Frankenthaler: middle-aged American clinician and infertility specialist; well dressed, preferably with tie and jacket. Ms Isabel Youngblood: host of TV programme Dissection; middle thirties, politically green and a strong critic of science and technology; stylishly dressed, preferably in trouser suit. Location TV studio of weekly "issues" programme, Dissection. This evening's topic was "Sex in an age of mechanical reproduction" with emphasis on techniques of assisted reproduction, such as in-vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI). Last scene Personal discussion between Youngblood and Frankenthaler after the end of a rather contentious TV programme. Frankenthaler Before I leave, may I ask you a question, Ms Youngblood? Do you have children? Youngblood I'm not accustomed to being interviewed by my guests. Frankenthaler We're now off camera. (Pause). Anyway, I take it the answer is "no." Now I won't ask how old you are, but I'd guess middle thirties. Youngblood Dr Frankenthaler, your personal questions have nothing to do with tonight's topic. Frankenthaler I beg to differ. They have a great deal to do with ICSI, because we have not addressed one issue of overwhelming importance. In fact, I'm surprised that you hadn't brought it up yourself during your show. Youngblood And what might that be? Frankenthaler Whether in the future fertile people might also resort to ICSI and other IVF procedures, rather than just those with infertility problems. Youngblood All right. I'll nibble on your bait. Why would normal people— Frankenthaler I didn't say "normal". I said "fertile". Youngblood I stand corrected. So why would fertile people spend thousands of dollars to produce a baby without sexual intercourse, when they can do it without cost and much more pleasurably in the usual way? Frankenthaler Fair enough. But that is why I asked whether you had any children and commented on your age. Youngblood What's my age got to do with it? Frankenthaler For argument's sake, let me assume that you have no children, that you are now 35, and that you do wish to have some children in the future, but not now. If you wait for another 5 years— Youngblood I have now stopped nibbling on your bait. Frankenthaler Relax! I was trying to generalise from a hypothetical Isabel Youngblood. Given that hypothetical age, just postponing childbearing from 35 to 40 years of age would at least quadruple your chances of giving birth to a baby with Down's syndrome. Youngblood I'm fully aware of that. It is one of the reasons why many pregnant women in that age group undergo amniocentesis. Frankenthaler Of course. But why? Because they are prepared to consider an abortion to terminate such a pregnancy if an extra chromosome is discovered during the testing. But as we discussed earlier in your programme, with ICSI, several embryos are available— Youngblood Sure. But for that, the woman would first have to undergo a course of hormone-induced superovulation to generate a supply of eggs. By no means a trivial procedure. Frankenthaler Yet something that millions of women have done— Youngblood Because they suffered from infertility problems, and IVF was their only option. I thought we were talking about fertile women? Frankenthaler So we are: about fertile women, who do not necessarily wish to wait for the third month of pregnancy to take the amniocentesis and potential abortion route. Such women could select preimplantation genetic diagnosis: looking for the same genetic markers as in prenatal testing, but doing so with a 3-day-old embryo before transfer into the uterus. Given such a scenario, she would simply discard the defective embryo and use another one. As I already pointed out during the programme, we are then not talking about abortion but selective reduction of the risk. For many women, especially those who do not consider a 3-day-old embryo in a petri dish a baby, this is not just a semantic quibble, because they might feel differently about a 3-month-old fetus in the uterus. And as more and more professional women postpone childbearing to that more dangerous age, some will also consider their access to preimplantation genetic diagnosis a sufficient incentive to undergo superovulation. Youngblood And that will cause millions of older women— Frankenthaler Just call them mature women. Youngblood Whatever! To stand in line at ICSI clinics to get their babies? Frankenthaler I didn't say millions. I don't know how many, but I believe the number will surprise all of us, at least in the affluent countries, notably in Europe and perhaps also Japan, where the average number of children is below 1·5 per family. And, of course, in the USA. It's an option they should not be denied. Especially because the rapid advances in genomics will allow us also to screen for certain other genetic markers—say a high predisposition to certain cancers. Youngblood And where will that stop, once we start looking for genetic markers? First one marker, then several, and then lots of markers? What kind of slippery slope are we then following? Frankenthaler In time, it may become quite slippery. Another reason why this topic ought to be discussed and debated. But making it illegal is unlikely to work, other than stimulating medical tourism, with its inherent discrimination in favour of the wealthy who can afford to indulge in such luxury. Youngblood So it's the possibility of preimplantation genetic diagnosis that will drive fertile women to consider IVF? Frankenthaler That might be the reason now, today, without further technical advances. But consider the fact that we now know how to store sperm and embryos for years— Youngblood (Laughs) And "cryopreservation" will become such a standard word that even cooks will talk about "cryopreservation" of food in the kitchen? Frankenthaler Think about the day, when we shall know how to store eggs or ovarian tissue in that way, a scenario we already discussed. It's almost here. I'd give it another decade or two and it will start becoming routine. Youngblood And? Frankenthaler And then offer young—not just mature—women the choice to undergo superovulation in their early twenties, when the quality of their eggs is far superior to those in their middle or late thirties. Youngblood And store their young eggs for eventual use by IVF years later? Frankenthaler As a reproductive insurance policy—for young women embarking on ambitious careers, who are not prepared to choose that early between motherhood and career—why not? Youngblood With their eggs in the bank, they might as well then get sterilised at that young age rather than practise contraception, and just check out an egg when they're ready for motherhood. Is that it? The end of the Pill and other contraceptives? Frankenthaler I'm sure that some will do that. Youngblood And why not men? Frankenthaler And men, of course. Especially since the technical difficulties of cryopreserving sperm for years or even decades have already been solved. Youngblood And you think that's good? Frankenthaler It's neither good nor bad. It's an option that should be available to those women, and men, who wish to exercise it. Youngblood I don't think we are talking science any more—or ICSI. Frankenthaler You're right. We're talking about women's choices—or religion. That's why it's time for me to leave. As a physician, I can present women with technical facts, but not with making the most important decision in their lives. (As he rises.) But would you mind if I offered one last piece of advice? Youngblood That depends on what it is. Frankenthaler Let me propose a theme for one of your future programmes. Youngblood Okay. Let's hear it. Frankenthaler "Are sex and fertilisation ready for divorce?" Youngblood I gather you think they are. Frankenthaler My opinion is not important. I'm talking about future generations, starting with those who right now are in school. They should debate that issue. Because they are the ones who will indulge in sex in an age of mechanical reproduction. Carl Djerassi, Professor of Chemistry Emeritus at Stanford University, is one of the few American scientists to have been awarded both the National Medal of Science (for the first synthesis of a steroid oral contraceptive) as well as the National Medal of Technology. In addition to many other awards, he is the recipient of 20 honorary doctorates (the latest in 2005 from Cambridge University). He is the author of five novels and six plays, two of which (An Immaculate Misconception and Taboos) deal with the ethical and social ramifications of assisted reproductive techniques. Carl Djerassi, Professor of Chemistry Emeritus at Stanford University, is one of the few American scientists to have been awarded both the National Medal of Science (for the first synthesis of a steroid oral contraceptive) as well as the National Medal of Technology. In addition to many other awards, he is the recipient of 20 honorary doctorates (the latest in 2005 from Cambridge University). He is the author of five novels and six plays, two of which (An Immaculate Misconception and Taboos) deal with the ethical and social ramifications of assisted reproductive techniques. Carl Djerassi, Professor of Chemistry Emeritus at Stanford University, is one of the few American scientists to have been awarded both the National Medal of Science (for the first synthesis of a steroid oral contraceptive) as well as the National Medal of Technology. In addition to many other awards, he is the recipient of 20 honorary doctorates (the latest in 2005 from Cambridge University). He is the author of five novels and six plays, two of which (An Immaculate Misconception and Taboos) deal with the ethical and social ramifications of assisted reproductive techniques.