This project explored the ethics of embryo research and assisted conception as experienced by professionals working in these fields, in both the public and private sectors. We explored professionals’ accounts of their values and how they actively negotiated ethical codes and rules in the course of their day-to-day work. We were especially interested in how practitioners managed the codes and rules set out by the Human Fertilisation and Embryology Authority (HFEA), public concerns about their work, and their own informal ‘moral thinking’. The project was based on three periods of observation, at an embryo research laboratory and at two IVF clinics, as well as fifty-two interviews with clinicians, scientists, nurses, counsellors, administrators and representatives of the HFEA.
We focused upon five main topics to explore these issues in depth: the ‘welfare of the child’, single embryo transfer, the rise of audit, managing mistakes and errors and the development of tests for embryo viability.
The way in which practitioners interpret the requirement that clinics consider the ‘welfare of the child’ in families accessing assisted conception services has changed as attitudes to IVF, single parents, and same sex couples have become more liberal. The HFEA recently changed the assessment procedure for clinics, focusing upon measurable risks and reducing the involvement of GPs. This reflects practitioners’ ambivalence about judging people’s suitability as parents. However, the process of deciding upon child welfare remains flexible, allowing for considerable subjective judgement on the part of professionals. This allows them to manage a complex range of professional, public and personal ethics around families, reproduction, disability and sexuality in reaching decisions about who and how to treat.
There has also been a recent shift towards single as opposed to multiple embryo transfer in assisted conception, to reduce multiple births in the public interest, as well as the interests of parents and their babies. Professional organisations and key practitioners have led this campaign, linking it to their efforts to secure more public funding for assisted conception. These assisted conception professionals are adopting a reflective, sociological approach to self-regulation that moves beyond their traditional efforts to protect clinical autonomy to a more complex negotiation of public and private interests and expertise.
Both of these developments are part of the growing culture of audit in assisted conception, where internal control systems based upon risk assessment have proliferated in the interests of political accountability. Although we found that practitioners broadly welcomed these developments as a means of securing public trust, there was more differentiation in their views of the pros and cons of particular audit mechanisms. We found that some more junior or marginalised staff were more positive about developing and following protocols when this empowered them in relation to their senior colleagues, but that other procedures such as double witnessing could generate anxiety and distrust rather than simple reduce error. Audit worked best when it involved ongoing feedback between the design and enactment of audit mechanisms.
This reflexivity was also at the heart of how professionals managed mistakes in assisted conception, as individuals, clinics and as a sector as a whole. Embryologists in particular have an acute sense of responsibility for the eggs and embryos that they steward. ‘System’ errors were easier to recount and resolve than situations where an individual was at fault. The codes and procedures that are put into place to prevent errors from reoccurring nonetheless involved individual staff and clinics sharing their personal experiences, including their sense of guilt and loss, with colleagues and the wider sector - a process that is generally welcomed by practitioners, for all of its difficulties. Refining risk management routines goes hand in hand with this kind of emotional labour – both are forms of ethics work.
Ethics also goes to the heart of the research process in assisted conception, especially efforts to find better ways of identifying ‘viable’ embryos. Research here becomes an ethical imperative in its own right, to improve success rates. However, this involves building a research culture in IVF and standardising the largely tacit knowledge and experience that embryologists use to assess embryos by looking at their morphology. Scientists, clinicians and commercial companies must therefore construct and market their notion of the ‘viable embryo’, being careful to stress its part of a wider move towards a more risk-aware IVF at the same time as distancing it from eugenic associations with ‘better babies’.
We conclude that the ethical framework set down in the HFEA’s Code of Practice is both flexible and iterative, in terms of how it is interpreted by practitioners and how it evolves in relation to social and scientific change. Ethics goes beyond the Code, involving a dynamic configuration of values, practices and procedures, which are embedded in research and treatment in assisted conception, as well as the wider work of practitioners on public and policy stages. There is considerable ambivalence amongst practitioners about the ethics of their decisions and about ethical scrutiny and controls of their work and their patients. Rather than viewing this as a cause for concern we suggest that doubt is a necessary condition of ethical practice in this complex and ever changing field of science and medicine.