Assisted Reproduction for HIV Serodiscordant Couples: The Ethical Issues in Perspective

Mark V. Sauer (2003) presents data and arguments supporting the claim that assisted reproduction should be offered to serodiscordant couples where the man is human immunodeficiency virus (HIV) positive. I will argue that it should probably be offered but the issue turns on the risks and harms to society and other infertile couples and not on considerations of the future child's or female partner's interests.

There are three sets of interests at stake: those of the future child, the female, and others (such as society generally and other infertile couples). I shall consider each in turn.

The Interests of the Child

Legislation governing assisted reproduction in the United Kingdom and Australia makes concern for the best interests of the child who results from assisted reproduction the paramount concern. This can be called the "best interests of the child" principle. Many commentators, including several in this volume (as well as the ethics committee of the Columbian Presbyterian Medical Center) seem to think that this principle speaks against allowing couples having a child when there is a risk of passing on HIV to the child, or at least when the risk is sufficiently high (Coleman 2003; Lyerly and Faden 2003; Spike 2003). Because the risk of a seronegative female contracting HIV from this procedure is very small and the risk of a seropositive woman on antiretroviral therapy having a child with HIV is very small, the risk that any child will be produced with HIV is very, very small. For example, if the risk of a woman contracting HIV is 1/1,000 and the risk of her passing this on to her baby is 1/50 (if precautions are taken to prevent infection), then the risk of producing a baby with HIV is 1/50,000. That is incredibly small. It is smaller than the risk of dying in a car accident in one year.

But it would also be reasonable for a woman to conceive a child by this means even if the chances of her having a child with HIV was 100%, at least from the perspective of the child produced. Here is why.

Consider first the different case in which the woman is HIV positive and the man is HIV negative. They request the use of assisted reproduction to lower his chances of contracting HIV during the attempt to produce a child. They produce an embryo and transfer this embryo to the woman. Unfortunately, despite precautions, she passes on HIV to her child, Gill.

Compare this now to the case where the woman provides an egg that is then washed. Assume for simplicity that there is no chance of HIV being present in a single washed egg. Her partner's sperm is inserted. The embryo is then transferred to another HIV-negative female surrogate. The baby is born without HIV. Call her Gillian.

Has the first child, Gill, been harmed by what her parents and their doctors did? Well, yes she has. Instead of the fertilized egg being transferred to her genetic mother's womb, it could have been transferred to a surrogate who would have no chance of transferring HIV after embryo transfer. This would have eliminated or at least reduced the risk of Gill contracting HIV. Gill could have been Gillian. She could have been born without HIV.

This argument implies that HIV serodiscordant couples where the female has HIV have a moral obligation to employ assisted reproduction and use an HIV-negative surrogate to maximally reduce the risk of any embryo of theirs going on to contract HIV. At least so the "best interests of the child" principle requires.

But now compare this to the situation where the male is HIV positive. The male produces sperm that is then treated to reduce the risk of transmitting HIV. It is then inserted in a single egg and back into the HIV-negative...