Ethical principles and the HFEA's donation review

At a public meeting on 19 October, the Human Fertilisation and Embryology Authority (HFEA) decided to move to a 'flat rate' system of monetary compensation for egg donors. They can now be paid £750 per cycle, regardless of actual expenses or loss of earnings (1). The HFEA also decided to leave the regulations governing egg sharing substantially unchanged.

According to the HFEA's definition, egg sharing 'is where a woman receiving IVF treatment donates some of her eggs, for either treatment or research, at the same time as undergoing treatment herself. In return, the clinic can offer a significant reduction in the cost of her treatment' (2).

Critics have already raised concerns about the quality of the discussion at the meeting; I shall not repeat these here (3). Instead, I want to look at a quite different issue: the use made by the HFEA of the idea of 'ethical principles'.

Early in the meeting papers it is stated that: 'The question as to what a fair compensation scheme looks like is essentially an ethical one. We therefore believe the right way of addressing the issue is through a principled approach to decision making' (4).

The paper goes on to list some principles that the HFEA had agreed should be taken into account including altruism, fairness, free choice, and the welfare of future children. There is much to be said for laying out one's principles and for taking a principled approach to decision-making, so this aspect of the Authority's approach is commendable. What is less satisfying is its failure to spell out what exactly these principles mean.

If an ethical principle is to be of any use it must guide our actions by stating that a particular type of action is morally required, or prohibited, or permissible and it should say something about the circumstances in which this is the case. It's not sufficient for it just to mention ethical keywords such as 'altruism' or 'autonomy'. Disappointingly, the Authority papers for the meeting do little more than that (without even having the excuse of lack of space, since they run to a full 424 pages). 

Does this matter? Isn't this just philosophical nitpicking?

It does matter — and it matters practically, not just intellectually — because different understandings of a principle can generate different prescriptions for action and policy. Altruism is a notable case in point. There are various different principles containing the word 'altruism'. These include:

(A) Donating body parts and/or products is wrong unless done purely for altruistic reasons.

(B) Donating body parts and/or products is wrong unless done (at least) partly for altruistic reasons.

(C) Donating body parts and/or products solely for personal gain (possibly including financial gain) is not wrong, but altruistic donation is morally better.

These are just three of many possible moral principles containing 'altruism' and each could generate very different recommendations.

If (A) were adopted, that would suggest limiting compensation for gamete donation to basic reimbursement of expenses. Many existing egg sharing arrangements would fall foul of this version of the Principle of Altruism, because egg sharers often receive treatment services worth many thousands of pounds and this can hardly be purely altruistic.

If (B) were adopted then mixed motives would be acceptable as well as purely altruistic ones. So even quite generously rewarded donation and sharing schemes could be permissible provided that donors were motivated partly by altruism.

Finally (C), like (B), suggests that we should tolerate generous financial compensation (and generous benefits in kind) whilst also encouraging and promoting unpaid donation. Also, on this view, we have reason to praise altruistic unpaid donors for their generosity in going beyond what is morally required.

So without knowing which particular version of the Principle of Altruism we should be committed to, we can't tell which policies are best supported by the idea of altruism.

One interesting practical application of this is in the seemingly different stances taken towards egg donation and egg sharing. Compensation for egg donors is capped at £750, while the benefits in kind that egg sharers may receive in the form of treatment services can be worth much more than this (with one cycle costing £2,500 - £5,000). So it seems that something like the most demanding version of the Principle of Altruism (A) has been applied to monetary compensation for donors, while a less stringent version (B perhaps) has been applied to egg sharing.

In defence of this apparent inconsistency, a number of possible justifications for treating donation and sharing differently have been offered. First, there is the argument that egg sharers have other laudable motives  as well as self-interest, such as altruism and feelings of solidarity with the recipient. This may well be true, but it is hard to see why it could not apply to at least some egg donors receiving payment; conversely some egg sharers may be motivated solely by a powerful desire to have children of their own.

Second, the HFEA papers note that people in general, and egg sharers in particular, view treatment as qualitatively different from payment. Perhaps they do, but how things are 'viewed' does not settle the question of whether they really are ethically different. Imagine, for example, a case in which a relatively wealthy woman, who can afford £5,000 for her own treatment, decides instead to become an egg sharer just in order to save that £5,000 (which she can then spend on other things). It is hard to see any real moral difference between this and another case in which the clinic simply gives her £5,000 for her eggs. For in both cases she ends up £5,000 better off, the clinic gets the eggs, and her aims and intentions (in opting to 'share' rather than pay) were financial.

Finally, the HFEA papers recommend 'that the Authority does not compensate donors the same amount as gamete sharers are entitled to receive — i.e., between £2500 - £5000 — on the basis that this would represent an inducement'.

This won't work partly for the reason just given; for at least some people, egg sharing just makes them better off financially than they would have been without the option to egg share (because they don't have to pay for treatment, even though they could have afforded to). And if this £5,000 (in benefits in kind) is not an 'inducement' for a sharer, why would a similar amount (in money) be an 'inducement' for a donor?

Furthermore, for egg sharers who are denied NHS (or further NHS) treatment — especially those who are less well-off financially — it is hard to see how offering them treatment services, when this may be their last chance to have a child of their own, is anything but an immensely powerful incentive to enter an egg-sharing scheme.

Is this then not also an 'inducement'? The answer of course depends largely on what one takes 'inducement' to be, and on what is thought to be wrong with 'inducing' people to do things. These issues, along with related ones about what counts as 'free choice', are also under-explored in the HFEA papers.

None of this is meant to imply that egg sharing is not a defensible practice or that it should be stopped. The point rather is a more fundamental one. When we appeal to 'ethical principles', their meaning needs always to be clearly stated. If this does not happen — if we do not get beyond listing keywords — it will be hard to tell whether the policies generated are consistent, justified, and based on sound ethical reasoning.