FILLING  THE  VOID:  AN  ANALYSIS  OF  THE  ETHICS  OF  POSTMORTEM  AND  PERSISTENT  VEGETATIVE  STATE  GAMETE  RETRIEVALS    

   BY      

T.J.  HOOKER    

A  Thesis  Submitted  to  the  Graduate  Faculty  of    

WAKE  FOREST  UNIVERSITY  GRADUATE  SCHOOL  OF  ARTS  AND  SCIENCES    

in  Partial  Fulfillment  of  the  Requirements    

for  the  Degree  of    

MASTER  OF  ARTS    

Bioethics    

December  2012    

Winston-­‐Salem,  North  Carolina      

Approved  By:    

Nancy  King,  J.D.,  Advisor    

John  Moskop,  Ph.D.,  Chair    

Liz  Johnson,  J.D.,  M.L.S.    

  ii  

DEDICATION    

  I  would  like  to  dedicate  this  thesis  to  my  wife.  Without  her  loving  support,  I  

would  never  have  written  a  word.      

  iii  

ACKNOWLEDGMENTS      

  First  and  foremost,  I  would  like  to  thank  my  advisor  Nancy  King  for  her  

patience,  support,  wisdom,  and  knowledge.  She  has  been  my  candle  in  the  darkness.  

I  cannot  thank  her  enough.  Second,  I  would  like  to  thank  both  John  Moskop  and  Liz  

Johnson.  Both  have  supported  me  tremendously  over  the  years  and  have  influenced  

my  thesis.    

  Also,  I  would  like  to  thank  the  following:  everyone  at  Wake  Forest  Center  for  

Bioethics,  Health,  and  Society,  Michael  Hyde,  Ana  Iltis,  Jay  Foster,  Louise  Winstanly,  

Pat  Corn,  Brad  Tharpe,  and  Angie  Hobbs.  All  of  these  people  have  encouraged  me  to  

become  a  better  student  and  writer.    

  Finally,  I  would  like  to  thank  my  wife  and  my  family  for  their  support.  They  

have  always  been  there  for  me  and  have  encouraged  me  to  finish  what  I  start.      

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TABLE  OF  CONTENTS  

 

Abstract                     v  

Introduction                     vi  

Chapter  1   Initial  PMGR  and  PVSGR  Distinctions  and  Concerns     1    

Chapter  2   Ethical  Considerations             12  

Chapter  3   Legal  Considerations               38  

Chapter  4   Social  Policy  and  Practical  Considerations         48  

Chapter  5   Hospital  PMGR  and  PVSGR  Policies           57    

Chapter  6   Alternatives  To  Hospital  Policy           78    

Conclusion                     84  

References                     87  

Appendix  I   Table  of  Hospital  Exclusionary  Criteria         93  

Curriculum  Vitae                   95    

  v  

ABSTRACT         In  1978,  Dr.  Cappy  Rothman  performed  the  world's  first  postmortem  gamete  

retrieval.   Since   this   time,   postmortem   gamete   requests   and   retrievals   have   been  

increasing.  Due   to   the   lack  of  both  regulation  and  professional  guidance,  hospitals  

have   begun   implementing   their   own   Postmortem   Gamete   Retrieval   (PMGR)   and  

Persistent  Vegetative  State  Gamete  Retrieval  (PVSGR)  policies.  

  This   thesis   addresses   the   difficult   ethical,   legal,   social   policy,   and   practical  

concerns  arising  from  PMGR  and  PVSGR.  In  the  first  chapter,  PMGR  and  PVSGR  are  

introduced.   In   the   second,   third,   and   fourth   chapters   the   ethical,   legal,   social,   and  

practical  concerns  are  identified.  This  thesis  argues  that  the  basic  right  to  reproduce  

may  extend  to  procreating  after  death  or  in  PVS.  The  key  ethical  consideration  is  the  

reproductive   autonomy   of   the   deceased   or   PVS   patient   and   the   type   of   consent  

needed   to   protect   the   patient's   autonomy.   This   autonomy   can   only   be   sufficiently  

protected  by  requiring  the  patient's  pre-­‐mortem  or  pre-­‐PVS  written  explicit  consent  

for   PMGR   and   PVSGR.   Therefore,   hospital   PMGR   and   PVSGR   policies   should   not  

honor   surrogate   decision  maker's   gamete   retrieval   requests   unless   they   have   the  

patient's   explicit   written   consent.   In   the   fifth   chapter,   this   thesis   compares   the  

similarities  and  differences  between  various  hospital  PMGR  and  PVSGR  policies  and  

approaches.   The   chapter   concludes  with   an   analysis   of   key   concerns   that   hospital  

PMGR  and  PVSGR  policies  must   address.   This   thesis   in   the   sixth   chapter   presents  

alternative   ways   that   PMGR   and   PVSGR   can   be   regulated   and   identifies   potential  

problems  these  alternatives  may  cause.  

   

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INTRODUCTION  

 

Developing  ways   to  ensure   the  survival  of  one's  own   legacy  past  death  has  

occupied   the  minds  of  physicians,  attorneys,  politicians,  and  people  worldwide   for  

centuries.  We  have  enacted   laws   to   control   and  disseminate  our  possessions  after  

our   death.   We   use   medicine   to   increase   our   longevity.   However,   despite   these  

efforts,  death  still   looms  with  a   finality   that   is  often  hard   to  accept.  Possibly   in  an  

attempt   to   accept   death,   we   have   developed   new   ways   to   ensure   our   genetic  

survival   after   death.   Although   procreation   after   death   has   only   recently   become  

medically  possible,  the  thought  has  occupied  minds  of  many  throughout  history.  In  

1866,   Paolo   Montegazza,   the   Italian   professor   and   scientist   who   discovered   that  

sperm   could   be   frozen,   quite   prophetically   envisioned   a  world  where   "a   husband  

who  has  died   on   a   battle-­‐field   could   [impregnate]   his   own  wife   after   he  has   been  

reduced  to  a  corpse  and  produce  legitimate  children  after  his  death."1  It  is  doubtful  

that  Monetgazza   could   have   anticipated   how   far  we  would   expand   on   his   idea   of  

procreating  after  death,  much  less  the  complex  issues  that  would  arise  from  his  idea.  

In  1790,  a  Scottish  anatomist  and  surgeon,  Dr.  John  Hunter,  reported  that  he  

had  successfully  retrieved  a  husband's  sperm  and  impregnated  the  husband's  wife  

using  the  sperm.2  For  over  a  century,  there  were  no  other  reported  cases  of  sperm  

retrieval  and  inseminations.  Then,  in  1884,  Dr.  William  Pancoast  performed  the  first  

human   donor   insemination   at   the   Jefferson   Medical   College   in   Philadelphia.  

However,  freezing  the  retrieved  sperm,  while  maintaining  viability,  did  not  become                                                                                                                  1  Clarke,  2006,  at  1649.  2  Fader.    

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a   possibility   until   1949.   The   first   successful   human   pregnancy  with   frozen   sperm  

was  reported  in  1953.  

In   the   1970's,   Doctors   Cappy   Rothman,   a   male   fertility   specialist   and  

urologist,  and  Charles  Sims,  a  pathologist,  were   looking  to  provide  a  way  to   lessen  

the  traumatic  effect  sterilization,  resulting  from  cancer  treatment,  has  on  men.  Both  

men   believed   that   a   man's   loss   of   his   ability   to   continue   his   family   name   often  

triggers   crisis   in   his   identity   and   negatively   impacts   his   self-­‐esteem.   They  

recognized   sperm   retrieval   and   cryogenic   preservation   as   a   solution   to   this   crisis  

and,  in  1977,  opened  a  sperm  bank  in  California.    

From   1949   to   1977,   gamete   retrievals   were   only   requested   by   and  

performed  on  males  anticipating  their  own  infertility  or  death.  However,  in  1978,  a  

new   possibility   emerged   when   Dr.   Rothman   received   a   unique   request   from   the  

family  of  a  30-­‐year  old  brain  dead  patient:  they  wanted  Dr.  Rothman  to  preserve  the  

dead  man's   sperm.   Dr.   Rothman   honored   the   family's   request   and   performed   the  

world's   first   successful   post-­‐mortem   gamete   retrieval.   But   Dr.   Rothman   was   not  

done.    

From   1978   to   1994,   Dr.   Rothman   alone   performed   post-­‐mortem   gamete  

retrievals   on   at   least   a   dozen   men.3  The   sperm   retrieved   from   these   deceased  

patients   "were   of   poor   quality."4  So   "the   families   simply   [kept]   the   sperm   as   a  

memento,   rather   than   [using]   it."5  This   changed   in   1995,   when   Gabrielle   Vernoff  

                                                                                                               3  Arthur,  1998.  4  Rothman,  1999.    5  Arthur,  1998.  

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asked  Dr.  Rothman  to  retrieve  her  dead  husband's  sperm.6  The  sperm  was  retrieved  

and   promptly   cryopreserved.   Then   in   1998,   Gabrielle   Vernoff   used   the   sperm   to  

become  pregnant.  In  1999,  her  daughter,  Brandalynn  Vernoff,  became  the  first  U.S.  

child  born  using  sperm  retrieved  from  a  deceased  father.7    

The  impact  of  Dr.  Rothman's  discovery  cannot  be  overstated.  Since  the  early  

1990's,  postmortem  gamete  retrieval  procedures  have  expanded  to  include  patients  

in  permanently  unconscious  states.  Also,  the  procedures  can  now  be  performed  on  

female   patients.   Dr.   Rothman's   discovery   has   created   a   world   where   death   and  

permanent   incapacity   no   longer   prevent   people   from   having   children;   a   world  

where  people's  heirs  can  be  born  years  after  their  death;  a  world  where  spouses  and  

parents   can   take   the   reproductive   materials   out   of   their   deceased   partner's   or  

child's  body  and  use   the  materials   to   create  a   child.  We  are  now   living   in  a  world  

where  we  can  cheat  death  and  tragedy  by  creating  life  from  death  and  tragedy.    

Postmortem  gamete  retrieval  (PMGR)  and  persistent  vegetative  state  gamete  

retrieval   (PVSGR)   generally   refer   to   surgical   procedures   where   deceased   or   PVS  

patients'  gametes  are  extracted  for  the  purpose  of  procreation.  However,  PMGR  and  

PVSGR   extend   beyond   the   surgical   procedure.   PMGR   and   PVSGR   occur   in   two  

stages.8  In  the  first  stage,  patients'  gametes  are  retrieved  and  stored.  In  the  second  

stage,   patients'   gametes   are   used   to   create   a   child   using   Assisted   Reproductive  

Technologies   (ART).   These   two   stages   are   distinct   because   different   specialists  

perform  the  retrieval  from  those  who  perform  the  ART.  A  third  party  must  request  

                                                                                                               6  Radford,  2009.  7News  Summary,  California  Baby  Born  Using  Sperm  From  Dead  Father.  8  Personal  Communications.  

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PMGR  or  PVSGR.  The  deceased  or  PVS  patient's  spouse,  intimate  partner,  or  family  

member  usually  makes  these  requests.9  Various  extraction  methods  exist,  including  

surgical   excision,   irrigation   or   aspiration,   and   rectal   probe   ejaculations.10  These  

gametes  are  then  frozen  for  future  use.    

From   1980   to   1995,   PMGR   requests   increased   only   sporadically.11  A   1997  

survey  of  40  fertility  facilities  reported  that  only  82  requests  were  made  during  this  

15-­‐year   period.12  Of   these   82   requests,  more   than   half   were  made   between   1994  

and  1995.13  Only  25  of  the  82  PMGR  requests  were  honored.14    

Many  commentators  agree  that  gamete  retrieval  procedures  are  on  the  rise.15  

Increasing  public  awareness   is  probably  driving   the   increase  of  requests.  Not  only  

are  more  procedures  being  developed  and  reported,  but  also  more  success  stories  

are  being  reported.  Headlines   intended  to  “shock  the  mind”  of   the  reader  grab  the  

attention   of   people   previously   unaware   that   PMGR   and   PVSGR   were   medically  

possible. 16  Headlines   such   as   “Mother   Creates   Life   After   Death” 17  and   “The  

Sperminator”18  are   published   in   newspapers   and   are   reaching   more   people.   As   a  

result,  more  PMGR  and  PVSGR  requests  may  be  on   the  horizon.  Already   there   is  a  

growing  concern  that  the  procedures  have  outpaced  law  and  ethics,  and  that  social  

boundaries  that  should  not  be  crossed  are  being  crossed.    

                                                                                                               9  Brock,  2005,  at  269;  Kahan,  1999.    10  Strong  et  al.,  2000.  11  Id.    12  Brock,  2005,  at  273.    13  Id.    14  Kerr  et  al.,  1997.  15  Brock,  2005.  16  Williams,  2011.  17  James,  2010.  18  Andrews,  1999.  

  x  

 Although   many   countries   have   addressed   these   concerns   by   passing   laws  

limiting   or   prohibiting   PMGR   and   PVSGR,   the   United   States   historically   has   not  

regulated  the  area  of  reproductive  medicine.19  In  addition,   there   is  no  professional  

universal   prohibition   of   PMGR   or   PVSGR   in   the   United   States.   Several   guidelines  

have  been  released  by  medical  societies  and  organizations,  but  these  guidelines  lack  

specificity,  leaving  most  medical  providers  and  specialists  to  their  own  professional  

discretion  on  the  matter.20    

Quite  possibly  because  of  the  lack  of  professional  guidelines  and  the  ethical,  

legal,   societal,   and   practical   complexity   of   PMGR   and   PVSGR,   hospitals   have   been  

“forced   to   draft   their   own   rules”   on   the   procedure.21  The   result   is   a   patchwork   of  

different  PMGR  or  PVSGR  policies.  Also,  it  is  unclear  how  accurately  hospitals  track  

and  monitor  their  own  PMGR  and  PVSGR  requests  and  their  responses.22  Currently,  

there  are  only  a  few  published  studies  reporting  the  prevalence  of  the  requests  and  

how  many  of  the  requests  are  honored.  Most  of  these  reports  are  dated  or  limited  to  

a   small   sample   size.   At   least   one   commentator   has   concluded   that   most   of   the  

requests  do  not  produce   children.23  It  may  be   that   as   few  as  one  out  of   every   five  

hundred  requests  produces  children.24  

This  thesis  presents  some  of  the  key  ethical,  legal,  social  policy,  and  practical  

concerns   raised  by  PMGR  and  PVSGR  procedures.  This   thesis   strongly   encourages  

hospitals  to  develop  and  implement  PMGR  and  PVSGR  policies  that  address  the  key  

                                                                                                               19  Bahadur,  2002.  20  James,  2010;  Orr,  2002.  21  Williams,  2011,  at  182.  22  Personal  Communications.  23  Strong  et  al.,  2000;  James,  2010;  Orr,  2002.    24  James,  2010.  

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concerns  raised  by  these  procedures.    

In  this  thesis  I  argue  that  only  the  deceased  or  PVS  patient's  previous  written  

explicit  consent  to  PMGR  or  PVSGR  sufficiently  protects  the  interests  of  that  patient.  

Therefore,  PMGR  and  PVSGR  should  not  be  performed  unless  the  medical  team  has  a  

patient's  written  explicit  consent  authorizing  them  to  perform  the  procedure  and  to  

use  the  retrieved  gametes  to  create  a  child.  I  argue  that  a  well  drafted  hospital  PMGR  

and   PVSGR   policy   plays   a   crucial   role   in   regulating,   controlling,   and   defining   the  

institutional  parameters  of  PMGR  and  PVSGR.  I  argue  that  hospital  gamete  retrieval  

policies  addressing  the  key  concerns  raised  in  this  thesis  are  currently  better  than  

two  alternatives:  legislation  and  professional  medical  organizations.    

This  thesis  is  divided  into  six  chapters.  In  Chapter  1,  I  identify  three  ways  life  

can  be  created  after  death,  analyze  the  differences  between  PMGR  and  PVSGR,  and  

explain  the  medical  procedures  commonly  used  to  retrieve  gametes  from  deceased  

or   PVS   individuals.   I   also   identify   some   key   differences   between  male   and   female  

gamete  retrievals  and  identify  eight  individuals  or  groups  who  may  have  an  interest  

in  the  procedure.      

In   Chapter   2,   I   explain   the   ethical   concerns   raised   by   PMGR   and   PVSGR.   I  

start   the   ethical   discussion   by   asking   whether   the   procedures   should   ever   be  

performed.  I  analyze  whether  reasons  given  for  creating  a  child  through  traditional  

methods  can  also  be  used  to  explain  why  an   individual  may  want  to  create  a  child  

after   death   or   while   in   PVS.   I   then   use   the   bioethics   principles   of   autonomy,  

nonmaleficence,   and   beneficence,   as   elucidated   by   Beauchamp   and   Childress,   to  

analyze  the  complex  ethical  issues  raised  by  PMGR  and  PVSGR.    

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In   Chapter   3,   I   explain   how   the   legal   problems   associated  with   PMGR   and  

PVSGR  arise  from  lack  of  precedent  on  the  issue.  The  legal  issues  may  be  separated  

into  those  that  arise  before  PMGR  and  PVSGR  and  those  that  arise   from  the  use  of  

the   retrieved   gametes.   This   chapter   explains   how   honoring   a   PMGR   or   PVSGR  

request  can  affect  inheritance,  Social  Security  survivor  benefits,  and  the  legal  status  

of  a  posthumously  born  child.    

In   Chapter   4,   I   address   the   social   policy   and   the   practical   concerns   arising  

from  PMGR  and  PVSGR.  These  policy  concerns  include  respect  for  the  dead  and  the  

welfare  of  the  child.  This  chapter  also  discusses  how  PMGR  and  PVSGR  procedures  

are  different   from  organ  donation.  Finally,  practical  concerns,  such  as  the  need  for  

institutional   consistency   and   the   costs   and   storage   issues   created   by   PMGR   and  

PVSGR,  are  addressed.  

In   Chapter   5,   I   introduce   eleven   hospital   PMGR   and   PVSGR   policies   and  

drafts.  This  chapter  analyzes  how  the  selected  hospital  policies   restrict  PMGR  and  

PVSGR   procedures.   I   then   analyze   whether   these   hospital   policies   address   the  

ethical,  legal,  social,  and  practical  concerns  raised  in  this  thesis.  

In   Chapter   6,   I   argue   that   hospital   policies   are   currently   the   best   way   to  

address   PMGR   and   PVSGR.   I   identify   some   alternatives   to   hospital   policies   and  

provide   arguments   for   and   against   these   alternatives.   I   conclude   that   these  

alternatives   are   currently   unable   to   properly   address   the   concerns   arising   from  

PMGR  and  PVSGR.    

  1  

CHAPTER  1:  INITIAL  PMGR  AND  PVSGR  DISTINCTIONS  AND  CONCERNS  

 

  The  following  three  hypothetical  cases  can  help   illuminate  the  complex  and  

often  abstract  discussion  of  the  ethical,  legal,  and  social  issues  of  PMGR  and  PVSGR  

procedures.    

Case   1:     Tim   and   Jane   are   married.   Although   they   have   been   married   for  

several  years,  they  do  not  have  any  children.  They  have  only  recently  felt  financially  

secure  enough  to  entertain  the  thought  of  children.  They  both  intend  to  draft  wills  

and  advance  directives,  but  can  never  get  around   to   it.  They  are  organ  donors.  By  

law,   Tim   and   Jane   are   each   other's   surrogate   decision   maker.     One   day,   Tim  

tragically  suffers  a  horrific  accident  and  dies  in  the  hospital.  Jane  is  distraught  over  

losing  the  love  of  her  life.  In  her  grief  Jane  tells  the  nurse  that  she  has  no  one  left  in  

her  life  now  that  Tim  is  gone.  She  tells  the  nurse  how  Tim  wanted  to  have  children  

to   share   the   child   raising   experience   with   her   and   to   carry   on   his   genes.   Jane   is  

inconsolable  now  that   the  possibility  of  having  Tim's  child  has  died  with  him.  The  

nurse,   wanting   to   help   Jane,  mentions   one   possibility   still   left   open   for   Jane:   The  

medical   team  could   retrieve  Tim's   sperm  and   Jane   could  use   that   sperm   to   create  

Tim's  offspring.  The  nurse  tells   Jane  that  time  is  of   the  essence  because  the  sperm  

can  only  be  retrieved  24  to  36  hours  after  Tim's  death.    

  Case  2:    Tim  and  Jane’s  relationship  is  the  same  as   in  Scenario  1.   Instead  of  

dying  in  the  hospital,  however,  Tim's  accident  puts  him  into  a  persistent  vegetative  

state.  Although  Tim  is  still  alive,  he  is  not  conscious.  Jane  is  distraught  with  grief  and  

is  offered  the  opportunity  to  request  that  Tim's  sperm  be  retrieved.    

  2  

  Case   3:     Tim   and   Jane's   relationship   is   different   than   the   previous   two  

scenarios.  Here,  Tim  is  nineteen,   in  college,  and  not   in  a  relationship.   Jane   is  Tim's  

mother.   Tim   has   told   Jane   that   he  wants   to   have   kids   one   day.   One   night,   Tim   is  

beaten  up  outside  a  bar  and  suffers  a   traumatic  brain   injury.  He  dies  shortly  after  

suffering  the  injury.  Since  Tim  is  Jane's  only  child,  she  is  inconsolable.  Jane  requests  

the   medical   team   to   retrieve   her   son's   sperm   to   preserve   his   legacy   and   help  

alleviate  her  own  grief.  

  In   the   three   hypothetical   cases,   Jane  makes   the   request   believing   that   Tim  

wanted   to   have   children.   How   should   the   medical   team   respond?   Some   relevant  

questions  include:  Should  PMGR  and  PVSGR  ever  be  performed?  Is  there  some  value  

in   honoring   PMGR   and   PVSGR   requests?   Should   PMGR   and   PVSGR   be   handled  

differently?  What  framework  is  needed  to  analyze  the  issues  of  PMGR  and  PVSGR?  

What  does  the   law  tell  us  about  the  procedures?  Should  the  hospital  have  a  policy  

that   guides   decisions   to   honor   or   deny   such   requests?   What   social   policies   are  

involved   in   the   decision?   If   PMGR   and   PVSGR   are   allowed,   should   the   patient's  

consent  be  required?  If  consent  is  required,  is  the  patient's  explicit  written  consent  

needed?  Can  the  patient's  surrogate  decision  maker  consent  to  the  procedure  using  

either   the   patient's   previous   unwritten   explicit   consent   or   by   using   substituted  

judgment?   Can   the   medical   team   rely   on   the   surrogate   decision   maker   if   the  

surrogate   decision   maker   is   related   to   the   deceased   or   PVS   individual?     Can   the  

medical  team  rely  on  the  surrogate  decision  maker  if  he  or  she  is  not  related  to  the  

patient?  Are  PMGR  and  PVSGR  different  from  organ  donation  and  if  so,  how  are  the  

procedures  different?  Is  grief  relief  a  valid  reason  to  perform  the  procedures?  

  3  

 

A.  How  Life  Is  Created  After  Death  or  PVS  

  To  understand  the  ethical,  legal,  social,  and  practical  complexities  caused  by  

PMGR   and   PVSGR   it   is   important   to   first   understand   the   differences   among   three  

possible   life   after   death   and   PVS   scenarios:   post-­‐mortem   births,   post-­‐mortem  

conception,  and  post-­‐mortem  and  PVS  gamete  retrievals.    

Post-­‐mortem  births:    The  post-­‐mortem  birth  scenario  is  the  most  common  of  

the   three   scenarios.   Post-­‐mortem   birth   is   the   result   of   voluntary   pre-­‐mortem  

conception   followed   by   the   death   of   at   least   one   parent   before   the   birth   of   the  

conceived   child.   Post-­‐mortem   births   have   occurred   since   the   beginning   of   human  

existence.  Any  time  a  rock  crushed  the  pre-­‐historic  man  and  that  man  left  behind  a  

pregnant  partner,   the  birth  of  the  child   is  designated  as  a  post-­‐mortem  birth.  War,  

disease,  and  sudden  death  are  all  key  contributors  to  post-­‐mortem  births.  Any  time  

a  man  goes  to  war,  leaving  behind  his  pregnant  partner,  there  is  the  possibility  that  

he  will  leave  behind  a  child  born  after  his  death.  Similarly,  a  man  can  suddenly  die  

from  disease  before  he  ever  sees  his  child's  birth.  Although  the  post-­‐mortem  birth  

scenario  is  tragic,  it  does  not  require  much  ethical  analysis.    

  Post-­‐mortem  conception:    The  post-­‐mortem  conception  scenario  is  different  

from  the  post-­‐mortem  birth  scenario.  Post-­‐mortem  conception  has  been  occurring  

in   the  U.S.   since   the  1950's   and   involves   a   purposeful   act   of   gamete   retrieval   and  

storage  while  alive  that  results  in  conception  after  death.25  Post-­‐mortem  conception  

results   from   pre-­‐mortem   voluntarily   retrieved   and   stored   gametes.   The   post-­‐

                                                                                                               25  Gottenger,  1999.  

  4  

mortem  conception  scenario  requires  individuals  to  plan  for  their  own  infertility  or  

death  and  willingly  deposit   their  gametes   for   safekeeping.  Conception   then  occurs  

when   the   stored   gametes   are   used.   For   example,   most   post-­‐mortem   conception  

scenarios   occur   in   cancer   treatment   situations   involving   men.   Some   cancer  

treatments   leave   men   sterile.   These   men   may   choose   to   have   their   sperm  

cryogenically   frozen   to   preserve   the   possibility   of   having   a   child   in   the   future,  

should   they   become   sterile   from   the   cancer   treatment.   If   the   treatment   does   not  

work  and  the  man  dies,  then  his  intimate  partner,  if  designated  as  a  recipient  of  the  

stored  gametes,  might  choose  to  use  the  man's  deposited  sperm  to  conceive  a  child.  

It   is  worth  noting,   that   this  practice   is  no   longer  provided  only   to  men,  as  women  

now  have  the  option  of   freezing  their  gametes  to  preserve  the  possibility  of   future  

children.   Also,   the   post-­‐mortem   conception   analysis   can   be   used   to   analyze   PVS  

conception.   The   main   difference   is   that   instead   of   a   child   conceived   after   the  

person's  death  from  their  stored  gametes,  a  child  is  born  after  a  person  enters  PVS  

and  leaves  behind  stored  gametes.    

  The   key   ethical   question   to   ask   in   the   post-­‐mortem   and   PVS   scenario   is  

whether   a  deceased  or  PVS  person,  who   leaves  behind  his   or  her   stored  gametes,  

wanted  or  would  have  wanted  his  or  her  gametes  to  be  used  to  create  a  PM  or  PVS  

child.   To   answer   this   question   another   one   must   be   asked:   Can   the   willful   and  

intentional  pre-­‐mortem  or  pre-­‐PVS  act  of  preserving  gametes  be  construed  as  intent  

to   have   those   gametes  used  posthumously   or  while   in  PVS   to   create   a  PM  or  PVS  

child?   Most   people   would   probably   agree   that   unless   the   donor's   wishes   were  

explicitly  stated,  it  is  not  clear  whether  the  donor  intended  the  gametes  to  be  used  

  5  

after   his   or   her   death.   Individuals   wishing   to   deposit   their   gametes   for   later   use  

often  sign  contracts  that  designate  the  recipients  of  the  deposited  gametes.  So  in  PM  

and   PVS   conception   situations   there   is   some   evidence   in   writing   that   strongly  

indicates  the  deceased  or  PVS  patient's  desire  or  prior  intent  to  procreate.  Often  this  

evidence  is  missing  in  PM  gamete  retrieval  scenarios.  

  PM  and  PVS  gamete  retrieval:    At  first  glance,  PM  conception  and  PM  and  PVS  

retrieval   scenarios   "seem   only   a   small   step   apart"   because   PM   and   PVS   gamete  

retrieval   scenarios   require   answering   some   of   the   same   questions   raised   by   PM  

conception.26  However,  PM  and  PVS  retrieval  scenarios  are  the  most  controversial  of  

the   three   life   after   death   scenarios.27  In   the   PM   retrieval   scenario,   there   could   be  

little  or  no  evidence  that  the  individual  wanted  to  procreate,  much  less  considered  

the  possibility  that  his  or  her  gametes  can  be  retrieved  and  used  to  create  a  PM  or  

PVS  child.28  In  these  scenarios,  death  or  PVS  often  come  suddenly  and  unexpectedly.  

The  suddenness  and  unexpectedness  of  the  death  or  PVS  denies  the   individual  the  

opportunity  to  create  a  will  or  advance  directive  indicating  how  his  or  her  gametes  

are  to  be  used.29  The  only  evidence  of  the  individual's  procreative  wishes  come  from  

statements  he  or  she  made  in  the  past.    

 

                                                                                                               26  Orr,  2010,  at  299.  27  PVS  also  needs  to  be  considered  in  the  PM  gamete  retrieval  scenario.    28  The  mere  fact  that  a  person  does  not  embody  his  or  her  wishes  in  a  written  document  does  not  necessarily  mean  that  he  or  she  did  not  consider  PMGR  and  PVSGR.  A  person  can  consider  PMGR  and  PVSGR  and  reject  the  procedures  through  their  silence,  or  can  have  considered  and  desired  these  options,  but  neglected  to  express  that  desire.    29  In  some  situations,  such  as  when  individuals  are  diagnosed  with  a  disease  or  cancer,  the  individual  may  have  the  opportunity  to  consider  PMGR  or  PVSGR  before  dying.  They  can  embody  their  wishes  in  a  will  or  an  advanced  directive.  This  opportunity  is  denied  to  individuals  who  die  suddenly  or  unexpectedly.    

  6  

B.  PMGR  and  PVSGR:  Definitions  and  Differences  

  An   individual   who   lacks   decision-­‐making   capacity  may   be   the   subject   of   a  

gamete   retrieval   request   while   in   two   states:   PM30  (right   after   death)   or   in   a  

permanent   unconscious   state   (PVS.)   Individuals   in   PVS   are   in   a   condition   of  

complete  unawareness  of   the  self  and   the  environment.31  PVS   is  a  vegetative  state  

present   after   acute   brain   injury   (traumatic   or   non-­‐traumatic)   or   in   patients   with  

degenerative  or  metabolic  disorders  or  developmental  malformations.32    

  Although   there   is   some  evidence   that  PMGR  procedures  may  be  performed  

beyond  32  hours  after  a  patient's  death,   the  general  consensus   is   that  PMGR  must  

take   place   within   24   to   32   hours   after   death.33  The   retrieval   time   limit   is   not  

applicable   in  PVSGR  situations.  The  patient  may  not  be  at  or  near  death  in  PVS,  so  

the  patient  may  continue  to  live  after  the  procedure  has  occurred.    

   

C.  Key  Differences  Between  Male  and  Female  Gamete  Retrievals  

  A  gamete  is  a  cell  that  fuses  with  another  cell  during  fertilization  and  forms  a  

new  organism.  So  by  definition,  "gamete"  includes  the  male  sperm  and  female  ovum.  

PMGR  and  PVSGR  have,   to   date,   only   been  performed  on  male   patients.  However,  

                                                                                                               30  Some  of  the  literature  uses  the  terms  perimortem  or  postmortem  when  describing  the  procedures.  I  have  determined  that  these  two  types  of  gamete  retrievals  require  similar  ethical  analysis.  In  perimortem  cases  the  patient  is  medically  determined  to  be  near  death.  In  these  cases  there  is  no  chance  that  the  patient  will  recover.  So,  the  sole  distinction  between  perimortem  and  postmortem  is  whether  there  is  a  difference  between  retrieving  gametes  from  those  that  are  legally  still  considered  alive  and  incidents  where  the  patient  is  dead.  Because  of  this  similarity  and  the  reality  that  surgeons  may  wait  until  the  patient  is  deceased  before  performing  the  surgery,  I  have  combined  the  two  states  into  one  for  ease  of  ethical  and  legal  analysis.  For  ease  of  discussion,  I  will  call  this  combined  category  PMGR  and  will  separate  the  two  states  only  if  an  important  distinction  needs  to  be  made.  The  other  category  I  will  refer  to  as  PVSGR.    31  The  Multi-­‐Society  Task  Force  on  PVS,  1994.  32  Id.    33  Shefi,  2006.      

  7  

recently   it   has  become  medically  possible   to   successfully   retrieve   viable   ova   from  

female   patients. 34  Therefore,   discussion   about   gamete   retrievals   should   also  

consider   the  possibility   that  a  husband  may  request  his  deceased  wife's  ova   to  be  

removed.    

  There  are  some  key  distinctions  between  male  and  female  gamete  retrievals.  

These   distinctions   may   require   different   ethical,   legal,   societal,   and   practical  

analysis.  The   first  key  distinction   involves   the  ease  of   access   to   the  gametes.  Male  

sperm  are  easier  to  access  and  not  all  sperm  retrieval  procedures  require  surgery.  

In   contrast,   female   ovarian   tissue   is   difficult   to   access   and   the   retrieval   methods  

always  involve  surgery.35  The  second  key  distinction  is  the  difference  in  viability  of  

male  and   female  gametes  retrieved  after  death.  Male  sperm  are  easier   to  preserve  

because   the   window   of   sperm   viability   after   death   is   larger.36  In   contrast,   female  

ovarian  tissue  remains  viable  for  only  a  few  hours.37  The  third  key  distinction  is  that  

different   medical   specialists   are   needed   to   perform   male   and   female   gamete  

retrievals.   Typically,   urologists   perform   most   male   gamete   retrievals,   while  

obstetricians   and   gynecologists   perform   most   female   gamete   retrievals.38  Finally,  

once  gamete  retrievals  are  performed,  there  may  be  differences  in  how  pregnancy  is  

achieved.  In  male  PMGR  and  PVSGR  situations,  the  retrieved  gametes  may  require  a  

gestational  carrier  other  than  the  requestor  only  if  the  requestor  is  unable  to  carry  

                                                                                                               34  Brock,  2005.  35  Id.  at  271.    36  Id.      37  Id.    38  Id.  

  8  

the   child   or   is   infertile.39  However,   in   female   PMGR   and   PVSGR   situations,   the  

requestor,  if  male,  will  always  require  a  gestational  surrogate  for  the  pregnancy.40    

  There   has,   as   of   yet,   been   no   reported   successful   PMGR   from   females.41  

However,  at  least  one  request  has  been  made  and  denied.42  A  full  comparison  of  the  

similarities   and  differences  between  male   and   female   gamete   retrievals   is   outside  

the  scope  of   this   thesis.  The   following  discussion  will  primarily  address   the   issues  

present   in   male   gamete   retrievals.   The   reader   only   needs   to   be   aware   that   it   is  

medically   possible   to   retrieve   female   ovarian   tissue   and   that   that  majority   of   the  

following  overarching  discussion  could  also  be  relevant  in  female  PMGR  and  PVSGR  

situations.      

     

D.  The  Procedures  

  Sperm  can  be  retrieved  from  deceased  males  whose  hearts  irreversibly  stop  

beating  and  from  deceased  males  whose  heartbeat  and  breathing  are  maintained  by  

machines  but   are  dead  by  neurological   criteria.43     Ideally,   sperm   is   retrieved   from  

brain   dead   individuals   within   a   24-­‐36   hour   window   from   the   time   of   death   by  

neurological  criteria.   It  may  be  possible  to  successfully  retrieve  sperm  up  to  forty-­‐

eight  hours  after  brain  death  by  neurological  criteria.44  When  a  male  patient  suffers  

                                                                                                               39  Id.  40  Id.  41  Knaplund,  2012,  at  922.    42  Greer,  et  al.,  2010.  43  Strong,  1999.  44  Tash  et  al.,  2003,  at  1923.  

  9  

irreversible   loss  of  heartbeat,   the  viability  of  the  sperm  decreases.  Sperm  retrieval  

must  then  occur  within  24  hours  to  obtain  viable  sperm.45  

  A  variety  of  procedures  exist  to  obtain  sperm  from  deceased  or  PVS  patients.  

When  Dr.  Rothman  conducted   the   first  PMGR  procedure,  he  performed  a  bilateral  

vasoseminal   vesiculectomy   during   a   midline   incision   at   the   time   of   organ   donor  

surgery.46  Sperm  has  also  been  retrieved  by  rectal  probe  electroejaculation47  and  by  

orchiectomy.48  Some  minimally   invasive   techniques  exist   such  as:   vasal   aspiration,  

microsurgical   epididymal   sperm   aspiration   and   testicular   sperm   extraction.49  The  

techniques   of   vasotomy   and   vasal   aspiration   are   the   preferred   treatment   because  

they  are  less  intrusive  to  the  dead.50  If  these  methods  do  not  produce  enough  viable  

sperm,   then   microsurgical   epididymal   sperm   aspiration   or   testicular   sperm  

extraction  can  be  used.51  The  medical  team  honoring  a  PVSGR  request  must  worry  

about   the   impact   the   gamete   retrieval   will   have   on   the   overall   health   of   the   PVS  

patient.  Therefore,   the  electroejaculation  procedure  should  always  be  used  on  PVS  

men   because   it   is   the   only   nonsurgical   procedure   available   and   it   is   less   invasive  

than  the  surgical  options.52      

     

 

 

                                                                                                               45  Strong,  1999.  46  Tash  et  al.,  2003,  at  1923.    47  Id.  48  Id.    49  Id.    50  Id.  51  Id.    52  Brock,  2005,  at  272.  

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E.  Identifying  PMGR  and  PVSGR  Interested  Parties  

  In   every   PMGR   and   PVSGR   request   there   are   at   least   eight   identifiable  

individuals  or  groups  whose  interests  need  to  be  considered:  (1)  the  PVS  or  recently  

deceased   patient;   (2)   the   PMGR   or   PVSGR   requestor/recipient;   (3)   the   possible  

future   child;   (4)   the  medical   team  caring   for   the  patient;   (5)   the  medical   retrieval  

team;   (6)   the   team   that   will   later   provide   assisted   reproductive   services   to   the  

recipient;   (7)   the   deceased   individual's   family;   and   (8)   the   hospital.   Deciding  

whether   or   not   to   honor   a   gamete   retrieval   request   requires   defining   and  

considering  these  interests.  

  The  PVS  or  deceased   individual  has  an   interest   in  his  or  her  own  body  and  

how  his  or  her  body   is   to  be  used.   I   believe   that   the  deceased  or  PVS   individual's  

interests   are   primary   and   should   usually   override   any   competing   interest.   The  

person  making  the  request  also  has  an   interest   in   the  gamete  process  because  the  

requestor   usually   has   a   reproductive   interest   at   stake.   The   future   child   has   an  

interest  in  the  process  because  the  decisions  made  before  the  birth  of  the  child  may  

affect  the  future  interests  of  that  child.53  The  deceased  or  PVS  individual's  family  has  

an  interest  in  PMGR  and  PVSGR  because  children  born  one  or  more  years  after  the  

individual's   death   may   affect   the   individual's   family   adversely   or   positively.   The  

individual's  family  also  may  have  a  moral  responsibility  to  protect  the  deceased  or  

PVS  individual's  interest  and  wishes.  

                                                                                                               53  It  may  be  incorrect  to  say  that  a  child  yet  to  be  conceived  has  an  interest  in  PMGR  and  PVSGR.  In  this  instance,  I  use  interest  only  to  indicate  that  the  future  child  needs  to  be  considered  when  analyzing  PMGR  and  PVSGR.    

  11  

  The   medical   care   team   has   an   interest   in   PMGR   and   PVSGR   because   they  

usually  receive  PMGR  or  PVSGR  requests.  The  medical  care  team  is  composed  of  the  

attending   physicians,   surgeons,   and   nurses  who   provided   pre-­‐mortem   care   of   the  

recently   deceased   patient   or   continue   to   provide   care   to   the   PVS   patient.   The  

medical   retrieval   team   has   an   interest   in   PMGR   and   PVSGR   because   they   are   in  

charge  of  performing  PMGR  or  PVSGR.  The  medical   retrieval   team   is   composed  of  

medical  specialists  and  gamete  storage  specialists.  The  ART  team  has  an  interest  in  

the  procedure  because  they  will  eventually  be  using  the  retrieved  gametes  to  assist  

in  the  conception  of  a  PM  child.  Finally,  the  hospital  has  an  interest  in  the  retrievals  

because   the   hospital   is   responsible   for   providing   safe,   efficient,   and,   if   feasible,  

economically  sound  services  to  hospital  patients.    

   

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CHAPTER  2:  ETHICAL  CONSIDERATIONS  

 

  In  PMGR  and  PVSGR  situations,  the  medical  team  must  consider  the  interests  

of  all  parties  and  make  a  decision  whether  to  perform  PMGR  or  PVSGR  within  hours  

of   receiving   a   request.  However,   the   ethical   issues   arising   from  PMGR  and  PVSGR  

are   difficult,   especially  when  hospitals   are   considering   their   first   PMGR  or   PVSGR  

request.  When  hospitals  are  faced  with  a  PMGR  or  PVSGR  request  and  they  have  not  

considered  the  ethical  issues  involved,  hospitals  risks  making  "ad  hoc  decisions  that  

may  result  in  actions  that  are  not  grounded  in  solid  principled  reasoning."54    

  The  complexity  of  ethics  involved  in  PMGR  and  PVSGR  is  a  major  reason  why  

hospitals   are  adopting  PMGR  and  PVSGR.  There   is   a   great  need   to  analyze  exactly  

what   ethical   concerns   should   be   considered.55  Debate   and   discussion   can   help  

alleviate  some  of  the  complexity.    

 

A.  Should  PMGR  and  PVSGR  Procedures  Be  Performed?  

  The  ethical  discussion  of  PMGR  and  PVSGR  should  always  start  by  asking  the  

overarching  ethical  question  whether  PMGR  and  PVSGR  should  ever  be  performed.  

Just  because  the  technology  exists  to  perform  PMGR  and  PVSGR  does  not  necessarily  

mean   that   the   retrievals   should   be   performed.     Even   in   instances   of   clear  written  

explicit  evidence  of  patients'  authorization  of  PMGR  or  PVSGR,  a  determination  must  

be   made   whether   such   authorizations   should   be   recognized   and   honored.   For  

example,  suppose  that  Paul  indicates  in  his  advance  directive  or  written  will  that  he                                                                                                                  54  Brock,  2005,  at  268;  Strong  at  739.  55  Strong,  2000,  at  741,  42.    

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would  like  his  gametes  to  be  retrieved  and  used  by  his  wife  for  procreative  purposes  

in  the  event  of  his  death  or  PVS.  Paul  dies.  Should  society  recognize  Paul's  choice  to  

procreate  after  death?  After  all,  if  procreating  after  death  is  determined  to  be  always  

inappropriate,   then   PMGR   and   PVSGR   procedures   may   not   be   "worthy  

of...consideration."56  Just   because   patients   authorize   PMGR  and  PVSGR  procedures  

does   not   necessarily   mean   that   PMGR   and   PVSGR   should   be   honored   because  

honoring  a  "choice  for  choice's  sake  is  not  a  compelling  principle  for  ethical,  legal,  or  

social  decision-­‐making."57    

  Procreative   liberty   is   widely   considered   a   fundamental   right   in   the   U.S.  

Procreative   liberty   is   a  broad   term   that   is  protected  by   the  Constitutional   right   to  

privacy   and   includes   the   right   to   procreate   and   the   right   not   to   procreate.58  The  

right   to   procreate   is   realized   when   couples   engage   in   "traditional"   acts   of  

procreation. 59  Also,   implicit   in   the   right   to   procreate   is   an   assumption   that  

"traditional"   forms   of   procreating   are   morally   permissible   ways   to   procreate.  

However,  PMGR  and  PVSGR  do  not  fall  in  the  "traditional"  definition  of  procreation.  

In  order  to  determine  the  moral  permissibility  of  PMGR  and  PVSGR,  we  are  required  

to  explore  how  PMGR  and  PVSGR  procreation  relates  to  "traditional"  procreation.  

  To   establish   a   connection   between   traditional   procreation   and   PMGR   and  

PVSGR,  some  reasons  given  by  people  wanting  to  procreate  in  the  "traditional"  way  

must  be  identified.  These  reasons  give  procreation  value.  These  reasons  must  then  

be  applied  to  PMGR  and  PVSGR  situations.  If  some  of  the  reasons  why  people  want  

                                                                                                               56  Katz,  2006,  at  294.  57  Robertson,  1994,  at  1033.  58  These  rights  are  discussed  in  more  detail  in  the  next  chapter.  59  By  traditional,  I  mean  coital  reproduction  before  the  advent  of  medical  non-­‐coital  reproduction.  

  14  

to  procreate   in   the   "traditional"  way   can   also  be  used   to   explain  why  people  may  

want   to   procreate   after   death   or   while   in   PVS,   then   there   are   some   reasons   for  

procreating   after   death   or   while   in   PVS.   Therefore,   in   at   least   some   instances,  

procreating  after  death  or  while  in  PVS  is  afforded  some  value.    

  To  determine  procreative  value  we  must  ask  why  the  choice  to  procreate  in  

the   "traditional"  way   is   important   to   people.60  Some   common   reasons   individuals  

provide   for   choosing   to   procreate   include:   the   desire   to   participate   in   creating  

another   person;   affirmation   of   mutual   love;   contribution   to   sexual   intimacy;   the  

experiences   of   pregnancy   and   birth;   and   the   experiences   of   child   rearing.61  Also,  

procreating  connects   individuals  with   future  generations  and  provides  personal,   if  

not   selfish,   experiences   through   contact   with   their   offspring.   These   reasons   have  

some   value   to   the   individuals   involved   because   they   provide   definition   and  

fulfillment   to   their   own   lives.   If   these   reasons   had   no   value   then   no   one   would  

procreate.    

  Once  reasons  for  traditional  procreation  are  identified,  these  reasons  need  to  

be  applied   to  PMGR  and  PVSGR  situations.  As  stated  above,  some  people  desire   to  

reproduce   because   of   the   genetic,   gestational,   and   child-­‐rearing   experiences  

involved.62  However,   someone   choosing   to   reproduce   after   dying   or   in   a   PVS   can  

share   only   some   of   the   traditional   reasons   given   for   why   people   choose   to  

reproduce.   These   are   the   desire   to   participate   in   creating   another   person   and  

affirmation  of  mutual  love.    

                                                                                                               60  Strong,  1999,  at  254.  61  Id.  at  255.  62  Robertson,  1994,  at  1031.    

  15  

  Another  important  question  to  ask  at  this  point  is  whether  it  is  a  meaningful  

reproductive   experience   to   know   in   advance   that   one's   gametes  might   be  used   to  

produce   offspring   after   one's   death.63  In   PM   and   PVS   situations,   a   person  may   be  

comforted  while  alive  by  the  fact  that  he  or  she  may  produce  offspring  after  death  or  

while  in  PVS.  In  addition,  PMGR  and  PVSGR  individuals  while  living  and  competent  

may  be  comforted  by  the  ability  to  control  their  legacy.      

  In   the   "traditional"   procreation   situation,   an   individual   has   the   right   to  

reproduce   and   can   directly   control   the   disposition   of   his   or   her   gametes.   For  

example,   individuals  exercise   this  right  by  choosing  who  they  want   to  have  sexual  

intercourse   with.   However,   deceased   and   PVS   individuals   can   no   longer   choose  

whom  they  have  sexual  intercourse  with.  They  no  longer  have  the  ability  to  directly  

control  the  disposition  of  their  gametes.  Instead,  these  individuals  can  only  make  a  

choice   if   their   pre-­‐mortem   or   pre-­‐incapacity   control   over   disposition   of   their  

gametes   is   extended  past   their  death  or   incapacity.   So,   even   though   there  may  be  

reasons   to   procreate   after   death   or   in   PVS,   it   must   be   determined   whether  

individuals'   pre-­‐mortem   or   pre-­‐incapacity   authority   to   control   the   disposition   of  

their  gametes  extends  past  their  death  or  incapacity.64    

  Society   has   recognized   individuals'   right   (or   interest)   to   control   their   own  

bodies.  These   interests  may  be  tied  to  our  personhood  or  because  of  our  property  

interest   in   the   parts.65     For   example,   individuals   are   permitted   to   "utilize   [their]  

                                                                                                               63  Id.  64  Although  this  issue  has  been,  for  the  most  part,  settled  in  the  courts,  it  is  an  issue  that  still  warrants  a  brief  analysis.  See  Chapter  3  for  further  discussion  of  the  issue.    65  Schiff,  1997,  at  909.  

  16  

body  parts   for   a   variety  of  purposes."66  Blood,   organs,   and   tissues   can  be  donated  

from  deceased  or   living  patients.   Similarly,   individuals  are  permitted   to  anticipate  

their   own   future   infertility   (and   in   some   cases   death)   and   have   their   gametes  

removed   and   frozen.   This   is   allowed   because   society   not   only   recognizes   the  

importance  of  procreation,  but  also  recognizes  that  procreation  is  a  personal  choice  

that   should   be   respected.   The   method   people   use   to   procreate   should   also   be  

respected.  This  recognized  respect  of  reproductive  choice  permits  people  depositing  

their  gametes   in  a  storage   facility   to  designate  the  recipient  of   those  gametes.   It   is  

not   a   leap   to   extend   the   same   type   respect   to   individuals  who  want   to   procreate  

after  death  or  in  PVS.  

  There  are  identifiable  reasons  why  individuals  procreate  in  the  "traditional"  

way.  These  reasons  give  traditional  procreation  value.  Some  of  these  reasons  can  be  

used  to  explain  why  some  individuals  may  want  to  procreate  after  death  or  in  PVS.  

So,  PMGR  and  PVSGR  have  some  value.  Furthermore,  individuals  have  the  authority  

to   control   how   their   gametes   are   to   be   used   in   the   event   of   their   death   or   PVS.  

Therefore,   the   choice   to   use   PMGR  or   PVSGR   to   procreate   should   be   respected   in  

some  instances.    

 

B.  Respecting  Autonomy  and  The  Issue  Of  Consent  

  In  the  section  above,  I  argued  that  PMGR  and  PVSGR  should  be  performed  in  

some   instances.   Analysis   now   shifts   away   from   determining   whether   PMGR   and  

                                                                                                               66  Id.  at  908.  

  17  

PVSGR  should  ever  be  performed  to  determining  in  what  situations  it  is  permissible  

to  perform  PMGR  or  PVSGR.  

  In  PMGR  and  PVSGR  situations,  the  deceased  or  PVS  individual's  autonomy  is  

at  stake.  But  what  is  autonomy?  If  the  dead  do  have  autonomy,  is  that  autonomy  as  

strong  as  when  the  individual  was  living?  Can  another's  autonomy  trump  a  deceased  

or  PVS  individual's  autonomy?  

  Personal   autonomy   can   be   defined   as   "self   rule   that   is   free   from   both  

controlling   interference   by   others   and   from   certain   limitations...that   prevent  

meaningful   choice."67  To   be   autonomous   an   individual   must   have   "independence  

from   controlling   influences"   and   have   "the   capacity   for   intentional   action." 68  

However,   individuals   rarely,   if   ever,   make   meaningful   choices   completely  

intentionally  and  without  influence.  Therefore,  a  choice  only  needs  to  substantially  

adhere   to   the   two   components   of   autonomy.69  In   gamete   retrieval   procedures,   a  

recently   deceased   or   PVS   individual   can   be   said   to   have   made   an   autonomous  

decision  when  that   individual   independently  and   intentionally  decided   to  have  his  

or  her  gametes  retrieved  and  used  after  death  or  in  PVS.    

  The  principle  of  autonomy  requires  others  to  recognize  and  respect  personal  

autonomy.  This  may  require  others  to  enable  an  individual  to  act  in  an  autonomous  

way. 70  To   respect   another   person's   autonomy   may   require   honoring   an  

incapacitated  individual's  previous  autonomous  choice  or  rendering  that  individual  

able  to  make  a  choice.    

                                                                                                               67  Beauchamp  and  Childress,  2009,  at  99.  68  Id.  at  100.  69  Id.  70  Id.  at  103.  

  18  

  Most   of   the   concerns   arising   from   PMGR   and   PVSGR   involve   determining  

how   to   respect   the   deceased   or   PVS   individual's   personal   autonomy.   Since  

individuals   in   gamete   retrieval   situations   are   either   deceased   or   permanently  

incapacitated   they   cannot  make   a   clear   contemporaneous   choice;   the   choice  must  

have  been  made  before  dying  or  suffering  the  trauma.    This  previous  choice  may  be  

referred  to  as  consent.71    

  To  properly  respect  a  deceased  or  PVS  patient's  autonomy  after  receiving  a  

PMGR   or   PVSGR   request,   the   medical   team   must   ask   two   questions:   (1)   Did   the  

patient   consent   to   the   gamete   retrieval   procedure?   (2)  Did   the  patient   consent   to  

having   his   or   her   gametes   used   to   create   a   PM   or   PVS   child?   I   think   a   PMGR   or  

PVSGR  should  not  be  performed  unless  the  answer  to  both  questions  is  yes.    

  Both  PMGR  and  PVSGR  situations  require  analyzing  whether  the  deceased  or  

PVS   individual   consented   to   the   retrieval   procedure   before   asking   whether   the  

individual  consented  to  having  his  or  her  gametes  used  to  create  a  PM  child.  So   in  

PMGR  and  PVSGR  situations  the  first  question  to  ask  should  always  be  whether  the  

individual   consented   to   the   gamete   retrieval   procedure.   Only   after   consent   to   the  

procedure   is   determined   can   consent   to   use   those   gametes   be   determined.   The  

answer   to   these   two   questions   depends   on   determining   what   type   of   consent  

sufficiently  protects  the  deceased  or  PVS  patient's  wishes  in  PMGR  and  PVSGR.  

                                                                                                               71  Consent  in  PMGR  and  PVSGR  is  not  necessarily  synonymous  with  typical  informed  medical  consent.  Medical  consent  occurs  after  an  exchange  of  information  between  the  doctor  and  the  patient,  where  the  doctor  offers  a  service,  and  the  patient  consents  (or  agrees)  to  the  offered  services.  Instead,  consent  in  PMGR  and  PVSGR  situations  is  defined  as  "pre-­‐mortem  [and  pre-­‐PVS]  permission"  for  the  procedures  and  subsequent  use.  However,  to  avoid  possible  confusion  and  to  remain  consistent  with  the  literature  discussing  PMGR  and  PVSGR,  I  will  use  the  word  consent.  See  Katz,  2006,  at  309.  

  19  

  There  are  four  distinct  ways  deceased  and  PVS  patients  can  consent  to  PMGR  

or  PVSGR.  The  first  way  patients  can  consent  to  PMGR  and  PVSGR  is  through  their  

written  explicit  consent.  For  example,  the  medical  team  may  decide  to  rely  on  Kurt's  

written  explicit  consent   if  he  has  executed  a   living  will   that  reads,  "In  the  event  of  

my  death  or  PVS,  I  want  my  sperm  to  be  retrieved  and  used  to  create  a  PM  child."  

The  second  way  patients  can  consent  is  through  their  surrogate  decision  maker  and  

what   the   patient   said   he   or   she   wanted   but   not   in   writing.   Generally,   surrogate  

decision  makers  may  make  choices  for  patients,  such  as  consent  to  PMGR  or  PVSGR,  

based   on  what   the   patient   said   he   or   she  wanted.   For   example,   the  medical   team  

may  decide  to  rely  on  Kurt's  verbal  consent  if  Kurt  told  several  people  that  he  would  

like  his  sperm  to  be  retrieved  in  the  event  of  his  death  or  PVS.  

  The   third   way   patients   can   consent   to   PMGR   or   PVSGR   is   through   their  

surrogate  decision  maker  who  determines  what  the  patient  would  have  wanted.   If  

the   surrogate   decision  maker   is   unclear  what   the   patient  wanted,   then   he   or   she  

may  make  medical  decisions  using   the  substituted   judgment  standard.  Substituted  

judgment  allows  surrogate  decision  makers  to  make  a  decision  for  patients  based  on  

what  the  patient  would  have  wanted.  A  fourth  way  consent  can  be  given  is  through  

the   surrogate   who   determines   what   is   in   the   best   interest   of   the   patient.   If   the  

surrogate  decision  maker  is  unsure  of  what  the  patient  would  have  wanted,  then  the  

surrogate  may  consent  to  the  procedures  by  determining  what  is  in  the  best  interest  

of   the   deceased   or   PVS   patient.   For   example,   if   Kurt's  mother   is   Kurt's   surrogate  

decision  maker,   then  Kurt's  mother  may   look  at  Kurt's  previous   statements  about  

wanting   to   start   a   family   to   determine   if   PMGR   or   PVSGR   is   something   that   Kurt  

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wanted,  would  have  wanted,   or  whether   it   is   in  Kurt's  best   interest.  As   I  describe  

later,  the  best  interest  standard  should  never  be  relied  on  in  PMGR  and  PVSGR.    

  Determining  what  type  of  consent  sufficiently  protects  patients'  reproductive  

autonomy   is   crucial   to  determining  whether  PMGR  and  PVSGR  procedures   should  

be  performed  in  any  given  situation.  So  what  type  of  consent  sufficiently  protects  a  

deceased  or  PVS  patient's  autonomous  wishes?  Can  only  the  individual  undergoing  

the   procedure   consent?   If   so,   does   the   individual's   consent   need   to   be   explicit  

consent   or   can   the   individual's   consent   be   inferred   from   their   actions?   What  

evidence   can   a   surrogate   decision  maker   rely   on   to   reach   a   consent   decision   for  

another   individual's   behalf?   How   can   the   surrogate   decision   maker   determine  

another  individual's  wishes?  If  a  surrogate  decision  maker  is  allowed  to  consent  on  

the  individual's  behalf,  what  problems  arise?  

 

Explicit  Written  Consent    

  When  hospitals   receive  PMGR  and  PVSGR  requests,   the  medical   teams  may  

be  presented  with  a  wide  variety  of  evidence  that  is  claimed  to  indicate  a  deceased  

or   PVS   patient's   consent   for   PMGR   or   PVSGR.   Many   commentators   agree   that  

patients'  written   explicit   consent   is   the  best   evidence   of   patient   consent   to  PMGR  

and  PVSGR  procedures.   In   reality,   however,   explicit  written   consent   in  PMGR  and  

PVSGR  situations  is  rare.72  Most  of  the  retrieval  requests  involve  patients  who  have  

not  expressed  a  desire  specifically   for  PMGR  or  PVSGR.  So  requests   for  PMGR  and  

PVSGR   will   most   likely   be   accompanied   with   non-­‐written   evidence,   which   the  

                                                                                                               72  Brock,  2005,  at  275.  

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requestor   claims   indicates   the   patient's   desire   for   children   even   in   the   event   of  

death  or  PVS.  

  I   think   that  written   explicit   consent   is   the   only   acceptable   type   of   consent  

that  can   indicate  a  patient's  desire   for  PMGR  or  PVSGR.  There  are  several   reasons  

why   explicit  written   consent   is   desirable   over   the   other   types   of   consent.   First,   if  

consent   indicates   state  of  mind,   then  patients'  written  express   consent   is   the  best  

evidence  of  patients'  choice  while   in   that  state  of  mind.73  Second,  patients'  written  

explicit   consent   for   PMGR   and   PVSGR   protects   patients'   reproductive   autonomy  

because   it   provides   "clear   and   unequivocal"   evidence   of   pre-­‐mortem   intent   for  

PMGR  and  PVSGR  and   indicates   "a  desire   to  parent  posthumously."74  As  discussed  

below,  this  kind  of  assurance  is  not  possible  with  the  other  types  of  consent.  Third,  

written   explicit   consent   takes   reproductive   decision   making   out   of   the   medical  

teams'  hands  because  the  medical  team  can  accept  the  written  consent  and  are  not  

required  to  weigh  evidence  of  patients'  intent.  Instead  the  patient  makes  the  choice.  

If   medical   teams   honor   only   PMGR   and   PVSGR   requests   accompanied   by   written  

express  consent  then  there  is  less  of  a  question  what  the  patient's  wishes  are.  This  

evidence   prevents   the  medical   team  having   to   question  what  may  be   best   for   the  

patient.  Fourth,  written  express  consent  places  the  burden  for  indicating  PMGR  and  

PVSGR  wishes  on   those  who  want   the  procedure   instead  of  placing   the  burden  on  

those  patients  who  may  not  want  the  procedure.  Evidence  suggests  that  substantial  

                                                                                                               73  Id.  74  Williams,  2011,  at  FN.  39.  

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portion   of   the   population   may   not   want   PMGR   or   PVSGR   to   be   performed   upon  

death  or  PVS.75    

  Some,   but   not   all,   of   the   types   of   documents   that   may   satisfy   the   written  

express   consent   requirements   for   PMGR   and   PVSGR   include:   wills,   advance  

directives,   health   care   power   of   attorney   forms,   and  medical   file   amendments   or  

notations.    

  One  problem  with  written  explicit  consent  involves  determining  whether  the  

written  document  accurately  reflects  deceased  or  PVS  patients'  wishes.  For  example,  

a  will   executed  by   a   patient   ten   years   ago   authorizing  PMGR  and  PVSGR  may  not  

accurately   reflect   the   patient's   current   wishes.   This   problem   is   inherent   in   all  

documents.  Even  with  this  problem,  written  explicit  consent  for  PMGR  and  PVSGR  is  

still  the  best  type  of  consent  medical  teams  have,  because  the  writings  may  be  less  

likely  to  be  misunderstood  than  previous  statements  or  actions.    

  Another   problem   with   relying   on   written   explicit   consent   to   indicate  

patients'  wishes   for  PMGR  and  PVSGR  arises   from   the   language  and   format  of   the  

current   forms  used  by  patients   to   inform   their  medical  providers  of   their   choices.  

For  example,  advance  directives  and  health  care  power  of  attorney  forms  usually  do  

not   state   or   provide   a   place   to   indicate   patients'   desire   for   or   against   PMGR   or  

PVSGR.   However,   some   advance   directive   forms,   such   as   North   Carolina's   health  

care  power  of  attorney   form,  contain  a  place  where  an   individual  may   limit  his  or  

her  agent's  power  to  decide  the  disposition  of  his  or  her  remains,  including  a  place  

                                                                                                               75  Barton,  2012,  at  737  (Half  of  the  respondents  did  not  want  their  partner  to  be  able  to  retrieve  their  gametes  in  the  event  of  their  death).  

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to   specify   these   powers.76  It   is   unclear   whether   indicating   on   the   form   special  

instructions  on  how   the  patient's  gametes  are   to  be   treated   is   the  proper  place   to  

indicate  such  instructions.    

  One  possible  way  around  the  problems  involving  statutory  advance  directive  

forms  may   be   to   amend   a   health   care   power   of   attorney   form   to   indicate   special  

instructions  for  gamete  retrieval  and  use  on  that  form.  Another  possible  alternative  

individuals   may   have   is   to   draft   an   organ   donation   card   and   expressly   indicate  

PMGR  and  PVSGR  wishes  on   that   card.   I   address   some  of   the  ways   legislation  can  

address  this  confusion  in  my  discussion  of  legislation  in  Chapter  6.  

 

Non-­‐written  Explicit  Consent  

  A   natural   question   to   ask   at   this   point   is   whether   explicit   non-­‐written  

consent   can   be   used   to   indicate   a   patient's  wishes   for   PMGR   and   PVSGR?   Several  

situations  can  be  imagined  where  a  patient's  prior  explicit  non-­‐written  consent  may  

just   as   strongly   indicate   a   patient's   desire   for   PMGR   or   PVSGR   as   explicit  written  

consent.  For  example,  suppose  that  Johnny  tells  his  wife  that  he  is  completely  open  

to   PMGR   or   PVSGR   and   would   love   to   procreate   after   his   death   or   PVS.   In   this  

example,  Johnny  has  uttered  his  explicit  verbal  consent  to  the  procedures.  However,  

Johnny  depends  on  another  person,  his  wife,  to  inform  the  medical  team  of  Johnny's  

desire.  There  is  a  lot  of  room  for  the  wife  to  interpret  Johnny's  explicit  statements.    

  If  the  goal  is  to  protect  Johnny's  choice  to  procreate  or  not  procreate  (I  argue  

this   should   be   the   goal   of   PMGR   and   PVSGR   hospital   policies),   then   relying   on  

                                                                                                               76  North  Carolina  Health  Care  Power  of  Attorney  Form    

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another   person   to   convey   Johnny's   choice   falls   short   of   the   goal.   In   addition,   if  

explicit  non-­‐written  consent  is  determined  to  sufficiently  indicate  a  patient's  desire  

for  PMGR  and  PVSGR,  then  hospitals  and  medical  teams  must  weigh  the  evidence  to  

determine  the  strength  of  the  evidence.  This  type  of  consent  incorrectly  places  the  

medical   team   in   charge  of   the  patient's   reproductive   choice;   a   choice  hospital   and  

medical  teams  usually  have  no  authority  over  in  traditional  procreation  situations.  If  

explicit   non-­‐written   consent   is   allowed   then   the   problems   of   determining   the  

sufficiency   of   that   consent   are   analogous   to   the   problems   that   arise   if   surrogate  

decision  makers  are  allowed  to  consent  to  PMGR  and  PVSGR.    

 

Problems  of  Surrogate  Decision  Makers    

  Usually,  a  family  member  serves  as  a  deceased  or  PVS  individual's  surrogate  

decision  maker.  Surrogate  decision  makers  are  generally  required  to  make  decisions  

consistent  with  the  best  interests  and  wishes  of  the  deceased  or  PVS  individual.  As  

discussed  at  the  beginning  of  this  section,  a  patient's  surrogate  decision  maker  may  

use   (1)   prior   statements  made  by   the  patient   concerning  PMGR,   (2)   a   substituted  

judgment  standard  to  determine  what  the  patient  would  have  wanted,  or  (3)  a  best  

interest  standard  to  determine  whether  PMGR  and  PVSGR  are  in  the  patient's  best  

interest.    

  If   the  surrogate  decision  maker   is  making  a  decision   for  a  deceased  or  PVS  

individual  using  the  substituted  judgment  standard,  she  or  he  is  required  to  make  a  

decision   the   deceased   or   PVS   individual   would   have   made   if   he   were   able   to.77  

                                                                                                               77  Beauchamp  and  Childress,  2009,  at  136.    

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According  to  Beauchamp  and  Childress,  this  standard  should  only  be  used  "if  reason  

exists   to   believe   that   the   surrogate   decision   maker   can   make   a   judgment   as   the  

patient  would   have  made   it."78  The   surrogate   decision  maker  would   need   to   offer  

reasons   why   the   individual   would   have   wanted   PMGR   and   PVSGR.   This   may   be  

indicated  by  certain  actions  or  patterns  the  deceased  or  PVS  patient  exhibited  while  

alive.   Also,   according   to   the   standard,   general   statements   about   wanting   to   have  

children  in  the  future  may  be  used  as  evidence  of  the  deceased  or  PVS  patient's  wish  

for  PMGR  and  PVSGR.    

  As   a   last   resort   and   when   medical   decisions   must   be   made,   surrogate  

decision  makers   sometimes   use   the   best   interest   standard   to  make   that   decision.  

According   to  Beauchamp  and  Childress,   the  best   interest   standard   should   only   be  

used   when   the   individual's   wishes   are   not   known,   and   the   surrogate   has   no  

knowledge  of   the  person’s  beliefs,   values,   or   goals   on  which   to  base   a   substituted  

judgment.79  The   surrogate   has   an   obligation   to   pick   a   choice   that   maximizes   the  

benefit  of  the  deceased  or  PVS  patient.  Also,  the  medical  team  also  has  an  obligation  

to   help   choose   what   is   in   the   patient's   best   interest.   However,   the   best   interest  

standard  is  used  to  address  medical  decisionmaking  relating  to  the  patient's  health,  

thus  using  the  best  interest  standard  in  the  PMGR  and  PVSGR  context  does  not  apply  

here.    

  One   problem   with   relying   on   a   substituted   judgment   standard   or   best  

interest  standard  is  that  if  past  statements  or  writings  do  not  anticipate  and  address  

the   specific   choices   at   issue,   they   cannot   reflect   what   the   individual   would   have                                                                                                                  78  Id.    79  Beauchamp  and  Childress,  2009,  at  138.  

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wanted.  For  example,  Bob  tells  his  wife  Gloria  several  years  before  he  dies  that  he  

would  like  to  start  a  family.  He  also  writes  a  poem  expressing  his  desire  to  have  kids.  

When   he   dies,   Gloria   makes   a   gamete   retrieval   request   and   uses   Bob's   past  

statements   as   evidence   proving   that   Bob   wanted   to   have   a   gamete   retrieval  

performed.  But  the  statements  or  writings  make  no  mention  of  having  PM  children.  

Bob  may  or  may  not  have  entertained  the  thought.    

  A   serious   problem   with   relying   on   surrogate   decision   makers   to   provide  

patient   consent   for   PMGR   and   PVSGR   procedures   is   that   the   surrogate   decision  

makers  are  usually  an  interested  party  standing  to  benefit  from  the  procedures.  The  

patient's   intimate   partner   or   family   members   usually   make   PMGR   and   PVSGR  

requests.   These   parties   are   also   usually   patients'   surrogate   decision   makers.  

Therefore,   patients'   intimate   partners   and   family  members  will   always   appear   to  

have  a  conflict  of  interest  because  they  stand  to  directly  benefit  from  the  gametes.80  

For   example,   Gloria   is   Bob's   surrogate   decision  maker.   She   has   always   wanted   a  

child   and   questions   her   ability   to   find   another   husband.   Gloria   requests   Bob's  

gametes   so   she  can  have  his   child.   Since   she   is   requesting   the  gametes   so   she  can  

become   pregnant,   it   is   reasonable   to   question   whether   Gloria   is   doing   what   Bob  

wanted,  or  would  have  wanted,  or  has  Bob's  best  interests  in  mind.    

  The  medical   team   is   morally   required   to   respect   their   patient's   autonomy  

whenever   reasonably   possible,   but   if   they   do   not   have   explicit   consent   the   team  

would  need  to  rely  on  other  evidence  indicating  whether  the  patient  wanted  to  have  

his  or  her  gametes  acquired  and  used  after  death  or  in  PVS.  While  this  evidence  may  

                                                                                                               80  Batzer  at  1266.  

  27  

exist,   the   evidence   is   usually   conveyed   by   others   and   may   be   inaccurate.   For  

example,  Gloria  is  overcome  with  grief  and  is  looking  for  a  way  to  replace  the  hole  

Bob's   death   has   left   in   her   life.   Her   grief   may   actually   prevent   her   from   viewing  

Bob's  past  actions  in  the  correct  light.  There  is  some  question  whether  Gloria  can  be  

relied  on  to  accurately  convey  Bob's  wishes.        

  Performing  PMGR  or  PVSGR  procedures  based  on  past  statements  uttered  by  

the   patient   and   filtered   through   an   interested   party,   based   on   the   belief   that   the  

patient  would   have  wanted   the   procedure,   or   based   on   the   belief   that   PMGR   and  

PVSGR   is   in   the   best   interest   of   the   patient,   is   questionable.   It   is   usually  

impermissible   to   take   reproductive   materials   from   individuals   (or   insert  

reproductive   materials   into   individuals)   unless   the   individuals   have   clearly  

consented   to  such  actions.   In   this   regard  Lori  Andrews   is   correct   in  asserting   that  

PMGR   and   PVSGR   procedures   are   morally   akin   to   rape   when   unaccompanied   by  

clear  patient  consent.81  The  rape  victim's  loss  of  control  over  her  own  reproductive  

autonomy   (as   well   as   the   usual   presence   of   violence)   makes   rape   a   morally  

deplorable   action.   A   rapist   cannot   defend   his   actions   by   asserting   that   his  

incapacitated   victim  would   have  wanted   to   have   sex,   or   that   his   victim   generally  

expressed  the  desire  to  have  sex  before  becoming  incapacitated,  or  that  the  victim's  

silence  on  the  issue  indicates  her  willingness  to  be  raped.  If  a  rapist  cannot  use  these  

justifications  for  rape,  why  should  PMGR  and  PVSGR  requestors,  hiding  behind  a  veil  

of  medical  procedures,  be  able  to  use  them?  

                                                                                                               81  Andrews,  1999.  

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  Due   to   the   inherent   conflict   of   interest,   potential   for   inaccuracy,   and   the  

alarming  resemblance  to  rape,  using  substituted  judgment  or  best  interest  evidence  

should  not  be  used  to  construe  patients'  consent  for  PMGR  and  PVSGR  procedures.  

Furthermore,  it  is  unreasonable  to  construe  a  patient's  silence  on  PMGR  and  PVSGR  

as   the   patient's   consent   to   have   the   procedures   performed.   Any   attempt   to  

determine  what   is  meant  by   the  patient's  silence  quickly  descends   into  a  guessing  

game.  Any  evidence  brought  in  to  support  the  contention  that  the  silence  somehow  

indicates   the   patient's   approval   is   circumstantial.   Therefore,   only   written   explicit  

consent  sufficiently  protects  patients'  choice  over  reproductive  matters  and  should  

be  relied  on  when  deciding  whether  to  perform  a  retrieval  procedure.  

 

Balancing  Competing  Claims  Of  Reproductive  Autonomy  

  In   discussing   reproductive   autonomy,   we   must   also   determine   whose  

reproductive   autonomy   should   be   given   priority.82  The   right   to   procreate   and   the  

right  not  to  procreate  are  fundamental  and  personal  decisions  and  implicate  "liberty  

and   privacy   rights   under   the   law."83  Both   the   deceased   or   PVS   individual   and   the  

individual's   spouse   have   legitimate   reproductive   autonomy   claims.   Should   a  

spouse's   reproductive   autonomy   be   able   to   trump   the   deceased's   reproductive  

autonomy?   Should   parental   PMGR   and   PVSGR   requests   for   their   son's   or   their  

daughter's  gametes  be  honored?  

  Most   PMGR   and   PVSGR   situations   involve   the   reproductive   autonomy  

interests   of   two   individuals,   the   patient   and   the   patient's   intimate   partner.   These                                                                                                                  82  Katz,  2006,  at  311.  83  Brock,  2005,  at  274.  

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two  interests  may  be  in  harmony  or  come  in  conflict  when  the  patient  dies  or  is  in  

PVS.  For  example,   a  patient's  wife  may   feel   that  her  husband's  gametes   should  be  

retrieved   because   the   marriage   relationship   entitles   her   to   his   gametes.   But   is   it  

necessarily  true  that  the  marriage  relationship  (or  any  other  intimate  relationship)  

alone  entitles  one  partner  to  the  reproductive  materials  of  the  other  partner?    

  There  are  four  distinct  situations  where  the  interests  of  the  patient  and  the  

patient's  intimate  partner  need  to  be  considered  together.  The  first  occurs  when  the  

patient   and   the   intimate   partner   both   want   to   procreate   after   death.   The   second  

situation  occurs  when  the  patient  wishes  to  procreate  in  the  event  of  incapacity  or  

death,   but   the   intimate   partner   does   not   want   to   procreate.   The   third   situation  

occurs  when  the  patient  does  not  want  to  procreate  or  has  not  expressed  an  explicit  

desire   to   procreate,   but   the   intimate   partner   wants   to   procreate.   The   fourth  

situation   occurs   when   both   the   patient   and   the   intimate   partner   do   not   want   to  

procreate.    

  The   first   situation   requires   determining   whether   there   are   reasons   and  

interests  to  allow  post-­‐mortem  conception,  which  I  have  done  in  the  first  part  of  this  

chapter.   Assuming   that   the   patient   made   his   or   her   wishes   explicitly   known   in  

writing  before  death  or  PVS,  then  the  couple's  wishes  should  be  granted.  The  second  

situation  does  not  require  the  medical  teams  to  weigh  reproductive  autonomy.  If  the  

intimate  partner  does  not  make  a  gamete  retrieval  request,  then  those  gametes  will  

not  be  retrieved.  To  force  the  intimate  partner  to  retrieve  and  conceive  would  most  

certainly  infringe  on  his  or  her  reproductive  autonomy.  The  last  category  does  not  

even   need   to   be   considered.   If   the   patient  makes   it   known   that   they   do   not  want  

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children  after  death  or  is  silent,  and  the  other  party  does  not  make  a  request,  then  

no  gamete  retrieval  will  be  performed.  The  most  difficult  situation  and  the  one  most  

commentators  are  concerned  with   is   the   third  situation.   In   the   third  situation,   the  

intimate  partner  may  try  to  convince  the  medical  team  that  his  or  her  reproductive  

autonomous  choice  should  be  substituted  for  the  patient's.  In  this  situation,  written  

express   consent   from   the   deceased   or   PVS   patient   should   be   required   before  

granting  the  intimate  partner's  request.    

  At  this  point,  it  is  necessary  to  discuss  the  proper  role  patients'  parents  and  

other   family   members   play   in   the   PMGR   and   PVSGR   process.   The   results   of   one  

study  suggest  that  a  majority  of  people  may  oppose  parents  having  access  to  their  

child's  gamete  for  the  purpose  of  reproduction.84  I  also  think  that  parental  or  family  

member  PMGR  and  PVSGR   requests   should  never   be   honored.   First,   if   the   goal   of  

PMGR   and   PVSGR   is   the   subsequent   procreation,   then   the   intimate   partner   can  

probably  achieve  this  goal  quicker  than  parents.  The  subsequent  procreation  from  

the   retrieved   gametes   is   probably   less   likely   to   occur   when   parents   obtain   the  

gametes.  Second,  allowing  parents  to  make  PMGR  and  PVSGR  requests  puts  them  in  

charge   of   their   children's   reproductive   autonomy.   It   allows   them   to   have   a   direct  

and   active   interest   in   their   children's   reproduction,   when   parents   usually   do   not  

have  this  interest.    

  Some   may   ask   how   PMGR   and   PVSGR   cases   where   parents   request   their  

deceased   or   PVS   child's   gametes   are   different   from   cases   where   parents   request  

their  child's  gametes  before  their  child  goes  through  cancer  treatment.  Arguably  the  

                                                                                                               84  Barton,  2012,  at  737.  

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goals  and  benefits  are  different.  In  cases  of  cancer,  parents  presumably  are  making  

the  choice  for  the  benefit  of  the  child  should  the  child  survive  the  cancer  and  want  

children   later   in   life.   The   parents   are   not  making   the   assumption   that   their   child  

would   have   wanted   future   children.   Instead,   the   parents   are   consenting   to   the  

procedure   in   the   event   their   child   does  want   future   children.   This   still   leaves   the  

ultimate   decision   whether   to   use   the   previously   retrieved   gametes   in   the   child's  

hand  and  preserves  the  child's  reproductive  choice.  Parents  should  only  make  this  

choice  if  it  is  in  their  child's  best  interest  and  only  until  their  child  becomes  mature  

enough   to   consent   to   gamete   retrievals   on   his   or   her   own.   If   parents   consent   to  

having   their   child's   gametes   retrieved   and   their   child   dies   or   enters   PVS,   then  

parents  should  not  be  allowed  to  use   their  child's  previously  retrieved  gametes   to  

create  a  child.    

     

C.  The  Principle  Of  Nonmaleficence  

  The  principle  of  nonmaleficence  requires  that  we  should  not  harm  others.  It  

is   the   negative   side   of   beneficence.85  The   principle   of   nonmaleficence   supports  

moral  rules  such  as:  do  not  kill,  do  not  cause  pain  and  suffering,  do  not  incapacitate,  

do  not  cause  offense,  and  do  not  deprive  others  of  the  goods  of  life.86  The  obligations  

of  nonmaleficence  also  include  the  obligation  to  not  impose  risks  of  harm.87    

  The  principle  of  nonmaleficence  is  central  to  the  question  whether  PMGR  and  

PVSGR  should  be  permitted   in  any  given  situation.  The  goal  of  protocols  or  policy  

                                                                                                               85  Beauchamp  and  Childress,  2009.  86  Id.  at  153.  87  Id.    

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involving   incapacitated   patients   is   to   "determine   the   best   system   for   protecting  

patients  from  negligence  and  harm."88  Generally,  families  are  in  the  best  position  to  

decide  what   is   best   for   their   incapacitated   loved  ones,   although  not   all   have   their  

loved  one's   best   interest   in  mind.  The  principle   of   nonmaleficence   can  be   seen   as  

advocating   the   development   of   a   "system   that   will   shield"   deceased   and   PVS  

individuals  from  family  members  and  others.89      

  The   principle   of   nonmaleficence   requires   identifying   what   is   meant   by  

"harm"   in   PMGR   and   PVSGR   situations.   The   term   harm   is   defined   as   "significant  

bodily  harms  and  other  setbacks   to  significant   interests."90  This  definition  of  harm  

does  not  require  the  existence  of  pain  but  an  actual  or  potential   ill  effect.  Both  the  

dead   and   living   persons   in   PVS   are   in   danger   of   being   harmed   because   their  

interests  may   be   overlooked   and   they   cannot   personally   protect   their   interests.91  

Much  like  the  issue  of  consent,  PMGR  and  PVSGR  patient  harms  can  be  divided  into  

two  questions:  (1)  How  is  the  patient  harmed  from  PMGR  and  PVSGR  procedures?  

(2)  How  is  the  individual  harmed  by  the  use  of  the  retrieved  gametes?  

  The  retrieval  procedure  can  physically  harm  the  deceased  or  PVS  individual.  

Of   course   deceased   individuals   cannot   feel   the   harm,   but   they   can   experience   the  

harm   if   the  body   is  unnecessarily  violated  or  mutilated.  Some  commentators  have  

compared   the   harm   caused   to   individuals   from   PMGR   procedures   to   the   harm  

caused   to   individuals   from   autopsies.   However,   the   procedures   are   different.   The  

harm   inflicted   on   the   deceased   during   an   autopsy   may   have   societal   and   policy  

                                                                                                               88  Id.  at  185.  89  Id.  at  186.  90  Beauchamp  and  Childress,  2009,  at  152.  91  Bahadur,  2002,  at  2773.  

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justifications.  Harm  caused  to  deceased  individuals  from  autopsies  is  justified  on  the  

grounds  that   investigating  the  cause  of  death  can  prevent  similar   future  deaths.   In  

contrast,  the  harm  inflicted  on  a  deceased  patient  during  a  PMGR  does  not  have  an  

overarching  societal  or  policy   justification.  The  harm  from  surgery   inflicted  on  the  

deceased   during   PMGR   is   not   a   benefit   to   the   patient,   unless   the   patient   clearly  

indicated  a  desire  for  PMGR  while  alive.  While  PMGR  patients  may  not  be  able  to  feel  

harm,   PVSGR   patients   may   be   able   to   feel   pain.92  Therefore,   care   must   be   taken  

when  retrieving  gametes  from  PVS  patients.    

  The   families  of  deceased  or  PVS  patients  can  also  experience  harm.  Certain  

family   members   may   view   PMGR   as   corpse   desecration.   This   desecration   may  

violate  laws  and  policy  designed  to  ensure  the  respectful  treatment  of  the  dead.  In  

addition,   some   family   members   may   view   the   electroejaculation   method   used   to  

retrieve  sperm  from  PVS  men  as  rape.    

  Both   the   deceased   patient   and   the   PVS   patient   can   be   harmed   by  

unauthorized   use   of   his   or   her   gametes.   For   example,   becoming   a   parent   against  

one's   wishes   may   constitute   a   harm.   The   patient   is   harmed   not   merely   because  

someone   who   carries   his   or   her   genetic   code,   but   is   harmed   by   "attribution   of  

parenthood.”93  If  a  living  person  is  considered  a  parent  by  society,  by  the  child,  or  by  

the   person   himself,   that   attribution   can   cause   harm   by   damaging   the   parent’s  

reputation  and  creating  unintended  economic  consequences.94  Furthermore,  a  child  

resulting   from   PMGR   and   PVSGR   can   "redefine   the   content   and   outlines   of   the  

                                                                                                               92  Coghlan,  2008.    93  Cohen,  2008,  at  1128.    94  Knaplund,  2012,  at  926;  Bahadur,  2002,  at  2773.  

  34  

deceased's   life"   and   "deprive   the   individual   the   opportunity   to   be   the   conclusive  

author  of...his  or  her  life."95  

  Also   the   decedent's   estate   and   preexisting   heirs  may   be   harmed  when   the  

decedent's  gametes  are  used  to  create  a  PM  child.  For  example,  the  decedent’s  estate  

may   be   obligated   to   provide   for   that   child   as   an   intestate   or   as   an   heir   yet   to   be  

born.96  This  may  harm  decedent's  existing  heirs,  who  now  have  to  split  their  share  

of  the  estate  with  a  posthumously  conceived  sibling.  This  type  of  harm  is  discussed  

in  the  next  chapter.    

 

D.  The  Principle  of  Beneficence  

  The  principle  of  beneficence  may  require  medical  providers  to  contribute  to  

other   people's   welfare. 97  The   principle   of   beneficence   can   be   split   into   two  

principles:   positive   beneficence   and   utility.98  The   principle   of   positive   beneficence  

requires  agents  to  provide  benefit  to  others.99  The  principle  of  utility  requires  that  

agents  weigh  benefits,  risks,  and  costs  to  produce  the  best  result.100    

  The  accepted  understanding  of  beneficence  is  that  we  are  morally  permitted  

to  help  or  benefit  those  with  whom  we  have  a  special  relationship,  but  not  required  

to  help  those  with  whom  we  do  not  have  a  special  relationship.101  The  principle  of  

beneficence   in   PMGR   and   PVSGR   situations   is   implicated   in   the   medical   team's  

relationship  with  the  deceased  or  PVS  individual  and  the  individual's  family.  One  of                                                                                                                  95  Bahadur,  2002,  at  2773.  96  Knaplund,  2012,  at  926.  97  Beauchamp  and  Childress,  2009,  at  197.  98  Id.  99  Id.    100  Id.  101  Id.  at  199.  

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the  health  care  professional's  primary  obligations   is   to  act   in  the  patient's  medical  

benefit.  Beneficence  often  appears  to  be  in  conflict  with  the  principle  of  autonomy,  

but   beneficence   may   be   defined   to   include   an   individual's   preference   when  

determining  what  counts  as  a  medical  benefit.102    

  The   medical   team   may   have   an   obligation   to   provide   only   beneficial  

procedures  to  their  patients.103  It  may  be  a  stretch  to  argue  that  PMGR  and  PVSGR  

procedures  benefit  deceased  or  PVS  patients.  The  procedures  harm  patients  because  

they   require   surgery   or   are   invasive.   However,   the   medical   team   may   provide   a  

benefit   in   performing   PMGR   and   PVSGR   by   helping   patients   realize   their   pre-­‐

mortem   or   pre-­‐PVS   wishes.   The   best   way  medical   teams   can   determine   whether  

PMGR   and   PVSGR   procedures   benefit   their   patients   is   through   patients'   written  

express  consent  for  the  procedures.    

  If   physicians  have  an  obligation   to  provide  only  beneficial   procedures   then  

there  may  be  some  confusion  as  to  whom  the  procedure   is  supposed  to  benefit.104  

Some  may  argue   that   the  medical   teams  owe  beneficence  not  only   to  patients,  but  

also   to   patients'   families.   This   argument   extends   the  medical   team's   professional  

role   as   healer   to   include   a   role   as   counselor.   Dr.   Rothman,   the   physician   who  

performed  the  first  PM  gamete  retrieval,  has  defended  his  actions  by  saying  that  "it  

could   actually   be   unethical   to   deny   the   hope   and   help   available   through   [gamete  

retrieval]   to   a   grief-­‐stricken   [spouse]..."105  Dr.   Rothman   has   even   retrieved   the  

                                                                                                               102  Beauchamp  and  Childress,  2009,  at  207.  103  Orr,  2010,  at  299-­‐303.  104  Id.    105  Rothman,  1999,  at  456  

  36  

gametes   from   a   unmarried   man   without   a   fiancée   and   reported   that   the   "man's  

father  was  greatly  consoled."106    

  As  mentioned  above,  Dr.  Rothman  and  other  physicians  may  view  their  role  

as   healer   to   include   consolation   at   a   time   of   grief   and   tragedy.107  Physicians  who  

share  Dr.  Rothman's   view   see  PMGR  and  PVSGR  as   a  way   to   alleviate   suffering  of  

family  members.     This  may   include  performing   gamete   retrievals   not   only   for   the  

patient's   intimate   partner,   but   also   for   the   family   members   making   PMGR   and  

PVSGR  requests.108  Physicians  who  hold  the  principle  of  beneficence  in  high  regard  

may  see  their  role  not  as  "deciding  whose  rights  to  [gametes]  should  prevail",  but  as  

"lessening  grief  and  offering  alternatives."109  

  I   question   Dr.   Rothman's   justifications   for   performing   PMGR   and   PVSGR  

procedures   on   his   patients.   Physicians   like   doctor   Rothman   in   an   understandable  

"attempt   to   sympathize"   with   intimate   partners   (or   families)   may   "automatically  

trust   their  motives"  behind  making   retrieval   requests.110  But   I   think   that   grief   can  

cloud  the  deceased's  partner's  judgment.  Grief  may  cause  the  patient's  "[partner  or]  

family  to  begin  to  feel  more  like  the  patient  than  the  individual  whose  gametes  are  

being  requested."111  This  grief  could  cause  the  intimate  partner  to  improperly  "use  

the   [deceased   or   PVS   patient]   as   a   means   to   [the   partner's]   own   end." 112  

Furthermore,   doctors   catering   to   these   emotionally   charged   requests   may  

experience   a   "shift   of   patient   perception,"   rendering   them   unable   to   properly                                                                                                                  106  Id.  107  Id.  108  Id.    109  Id.  at  457.  110  Cannold,  2004.  111  Brock,  2005,  at  271.  112  Cannold,  2004.  

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"appreciate   the   risk   of   [retrieving   the   gametes]   without   the   deceased   or   [PVS]  

person's   consent."113  Using   the   principle   of   beneficence   to   treat   the   patient's  

family's  grief  can  cause  the  medical  team  to  ignore  their  deceased  or  PVS  patient's  

autonomy.  Therefore,  PMGR  and  PVSGR  should  not  be  undertaken  solely  to  treat  a  

patient's  family's  grief.  

   

                                                                                                               113  Brock,  2005,  at  271.  

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CHAPTER  3:  LEGAL  CONSIDERATIONS  

 

  In  a  way,   the  answer   to   the  question  whether  PMGR  or  PVSGR   is   "legal"   to  

perform  is  the  low  hanging  fruit  on  the  gamete  retrieval  tree  of  problems.  There  is  

currently   no   legislation   or   case   law   that   directly   addresses   whether   PMGR   and  

PVSGR   procedures   are   "legal"   to   perform.   Instead   there   is   a   tacit   recognition   in  

current   legislation  and  case   law  that  PMGR  and  PVSGR  should  be  allowed  in  some  

instances.   However,   what   is   legal   is   not   always   ethical   and   many   people   are  

uncomfortable  with   a   tacit   yes   to   such   a   controversial,   and   sometimes   unsettling,  

procedure.114  Even   some   courts   recognize   that   the   issues   arising   from   PMGR   and  

PVSGR  "cry  out  for  a  lengthy,  careful  examination  outside  the  adversary  process."115  

  Currently   PMGR   and   PVSGR   are   occurring   in   what   may   be   called   "a   legal  

void."116  Assisted  reproduction  in  the  U.S  is  largely  unregulated  and  not  extensively  

litigated.  All  gamete  retrievals  that  have  been  performed  so  far  are  done  "without  a  

legal   backbone."117  PMGR   and   PVSGR   procedures   are   not   legally   prohibited   and   a  

limited   body   of   case   law   deals   with   the   problems   caused   by   posthumous  

procreation.  These  problems   involve  either   the   right  an   individual  has  over  his  or  

her  own  reproductive  materials  or  the  rights  of  post-­‐mortem  born  children.118    

 

 

                                                                                                               114  Andrews,  1999.  115  Woodward  at  556-­‐57.  116  Katz  ,  2006,  at  299.  117  Williams,  2011,  at  182.    118  Sutton  at  859.  

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A.  Constitutional  Rights  and  Bodily  Integrity  Rights  

  The  U.S.  Constitution  does  not  contain  a  fundamental  right  to  procreate  and  

to   not   procreate. 119  However,   the   courts   have   established   "constitutional  

safeguards"  that  have  historically  protected  this  right.120  The  Supreme  Court  has  not  

formally  recognized  a  fundamental  right  to  procreate,  but  has  ruled  on  several  cases  

that  imply  the  right  exists.  121  For  example,  the  Supreme  Court  has  recognized  that  a  

person's   decision   to   bear   children   is   covered   by   the   constitutional   right   to  

privacy.122  The  Supreme  Court  has  yet  to  determine  whether  this  fundamental  right  

extends  to  individuals  who  wish  to  reproduce  posthumously.  The  Court  also  has  not  

directly  addressed  PM  born  children's   rights.  Therefore,  PM  born  children's   rights  

are  determined  at  the  state  level  and  vary  from  state  to  state.    

  Although   there   is   not   a   constitutional   right   to  procreate   (or  not   procreate)  

posthumously,   legislation   and   courts   have   afforded   the   dead   certain   rights   over  

their  bodies  and  how  their  bodies  are  to  be  treated.  These  "bodily  integrity  rights"  

include   the   right   to   control   disposition   of   one's   own   body,   such   as   burial  

instructions  and  organ  donation.123  However,  bodily  integrity  rights  are  only  "rights  

in  a  qualified  sense",   and   the  deceased  cannot  defend  violations  of   these  rights.124  

Instead  the  decedent's  family  members  or  an  interested  third  party  must  bring  the  

cause  of  action.  What  this  means  is  that  any  "assertion  that  a  cadaver  has  a  right  to  

                                                                                                               119  Elliot,  2004,  at  55.  120  Id.  121  Griswold  v.  Connecticut;  Eisenstadt  v.  Baird.  122  Elliot,  2004,  at  56.    123  Knaplund,  2012,  at  924.  124  Pierce  v.  Proprietors  of  Swan  Point  Cemetery,  at    239.  

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bodily   integrity,   and   thus   a   cause   of   action   if   his   or   her   gametes   are   retrieved  

without  pre-­‐mortem  consent,  is  tenuous  at  best."125      

 

B.  Property  Rights  in  Gametes  

  An  individual's  right  to  control  his  or  gametes  is  a  central  issue  in  PMGR  and  

PVSGR.  The  question  is  whether  an  individual  can  give  his  or  her  gametes  to  another  

individual   for   the   purpose   of   procreation   after   death.   After   struggling   with  

classification  of  reproductive  materials,  the  general  consensus  reached  by  the  courts  

is  that  gametes  are  not  property  in  strictest  term,  but  "occupy  an  interim  category  

that   entitles   them   to   special   respect   because   of   their   potential   for   human   life."126  

The  leading  case  addressing  PM  conception  and  property  rights  is  Hecht  v.  Superior  

Court.127    

  In  Hecht,  William  Kane  committed  suicide  after  depositing  his  sperm  into  a  

sperm   bank.   Before   his   death,   Kane   had   signed   a   release   form   to   have   his   sperm  

released   to   his   girlfriend,   Deborah   Hecht.   Kane   also   executed   a   will   that   further  

stated   his   sperm   should   be   released   to  Hecht.   Kane's   previous   children   contested  

the  will  and  release  form.  

  In   Hecht,   the   court's   analysis   centered   on   what   property   interests   an  

individual  has  over  his  or  her  own  body.  The  court  recognized  sperm  as  a  "unique  

type  of  property"  due  to  sperm’s  ability  to  create  another  life.128  The  court  held  that  

Kane   had   ownership   interest   in   his   gametes   and   could   use   his   "decision   making  

                                                                                                               125  Knaplund,  2012,  at  925.  126  Davis  v.  Davis  at  597.    127  Hecht  v.  Superior  Court.  128  Id.  at  283.    

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authority"  while  alive   to  control  how  his  gametes  were   to  be  used  after  his  death.  

Perhaps  more  importantly,  the  court  also  held  that  post  mortem  conception  was  not  

against  public  policy.  In  addition,  the  court  determined  that  the  judiciary's  role  does  

not   include   inhibiting   the   use   of   reproductive   technology   "when   the   legislation   is  

silent  on  the  issue."129  The  court  reasoned  that  doing  so  would  raise  questions  of  the  

"fundamental  nature  of  procreation  and  privacy."130    

  In  A.Z.   v.   B.Z.,   a  Massachusetts   case   considering   certain   issues   surrounding  

the  disposition  of  frozen  pre-­‐embryos,  the  court  recognized  that  individuals  have  a  

protected   right   to   control   the   use   of   their   gametes.131  The   court,   recognizing   the  

value  of  bodily  and  reproductive  integrity,  refused  to  force  a  husband  to  become  a  

parent   and   held   that   "forced   procreation   is   not   an   area   amenable   to   judicial  

enforcement."132    

 

C.  Social  Security  Survivor  Benefits  

  If  any  area  of  the  law  involving  PM  conception  (thus  relevant  to  PMGR)  can  

be   perceived   as   extensively   litigated,   it   is   the   area   of   Social   Security   survivor  

benefits.  Most  of  the  cases  in  this  area  involve  the  surviving  parent  suing  on  behalf  

of   his   or   her   child   so   the   posthumously   conceived   child   can   receive   his   or   her  

deceased  biological  parent's  Social  Security  survivor  benefits.    

                                                                                                               129  Hecht  v.  Superior  Court  at  290.  130  Id.    131  A.Z.  v.  B.Z.  132  Id.  at  160.  

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  In  one  case,  a  prolonged  court  battle  was  avoided  and  the  PM  child  received  

survivor  benefits.133  Shortly  after  marrying  Nancy  Hart,  Ed  Hart  developed  cancer.  

Ed,  anticipating   the  possibility   that   the  cancer   treatment  would  render  him  sterile  

or   simply   not  work,   chose   to   have   some   of   his   sperm   stored   in   a   sperm   bank.   In  

1990,   Ed   passed   away   and   Nancy   used   the   frozen   sperm   to   become   pregnant.   In  

1991,   their   daughter   Judith  was   born.   Nancy   then   tried   to   receive   Social   Security  

survivor   benefits   for   Judith.   The   Social   Security   Administration   (SSA)   denied  

Nancy's   claim   because   Louisiana   law   did   not   recognize   a   child   born   after   death  

through   artificial   insemination   as   a   legal   heir   of   the   deceased   individual.   Nancy  

appealed   the   decision   and   the   SSA   settled   the   case,   awarding   her   child   survivor  

benefits.    

  After  the  Harts’  case,  Social  Security  survivor  benefit  cases  end  up  going  the  

other  way.  In  Woodward  v.  Commissioner  of  Social  Security,  Woodward  was  denied  

benefits  for  her  twin  daughters  conceived  from  her  husband's  sperm  two  years  after  

his  death.134  In  Woodward,   the  sperm  was   frozen  before   the  husband's  death.  The  

Massachusetts   Supreme   Court   recognized   that   PM   children   could   enjoy   the   same  

inheritance   rights   as   children   not   created   posthumously.   To   do   so,   the   court  

required  Woodward  to  prove  three  things:  1)  the  genetic  relationship  between  the  

father   and   daughters,   2)   that   the   father   consented   before   his   death   to   have   his  

frozen  sperm  used  by  his  wife  for  the  creation  of  PM  children,  and  3)  that  the  father  

had   consented   to   support   all   PM   children   before   his   death.  Woodward   could   not  

                                                                                                               133  Elliot,  2004,  at  60-­‐62.  134  Woodward  v.  Commissioner  of  Social  Security.  

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prove  that  her  husband  had  consented  to  support  his  PM  children  before  his  death  

and  her  children  were  denied  the  survivor  benefits.  

  In  Veroff  v.  Astrue,  Brandalynn,  the  first  child  born  in  the  U.S.  by  PMGR,  was  

required  to  establish  that  she  was  the  natural  child  of  her  father  or  a  dependent  of  

her  father  when  he  died.  Brandalynn  was  required  to  show  dependency,  her  father's  

intent  to  father  and  support  her,  and  her  right  to  inherit  from  her  father.  Brandalynn  

could  not  prove   the   first   two  requirements  because  she  was  born   four  years  after  

her   father's   death.   So   the   court   held   that   she   could   not   inherit   or   obtain   Social  

Security  survivor  benefits.135    

  In   May   2012,   the   Supreme   Court   finally   ruled   on   the   issue   whether   PM  

children  could  receive  Social  Security  survivor  benefits  of  their  deceased  parent.  In  

Astrue   v.   Capato,   the   Court   held   that   Social   Security   survivor   benefits   are  

"[designed]  to  primarily  benefit  those  supported  by  the  deceased  wage  earner  in  his  

or   her   lifetime."136  The   Court   ruled   in   favor   of   the   SSA   and   required   survivor  

benefits  to  be  determined  by  looking  at  each  state's  intestacy  laws.137  This  does  not  

bode  well   for   PM   conceived   children   living   in   some   states.   For   example,   in  North  

Carolina  PM  conceived  and  born  children  applying  for  their  parent's  Social  Security  

survivor  benefits  will  probably  be  denied  such  benefits.  North  Carolina  law  does  not  

recognize  children  born  ten  months  or  more  after  their  parent's  death  as  the   legal  

heir  of  the  deceased  parent.138    

 

                                                                                                               135  Williams,  2010,  at  188.  136  Astrue  v.  Capato  at  2026.  137  Id.  at  2027.    138  N.C.  Gen.  Stat.  §  29-­‐9  

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D.  Estate  Law  

  In   cases   of   estate   disbursement,   the   decedent’s   heirs   are   likely   to   pursue  

judicial   remedies   to   prevent   PMGR  or   PVGR  procedures   or   subsequent   use   of   the  

retrieved   gametes.139  In   this   area,   there   are   tensions   between   a   posthumous   born  

child's  right  to  inherit  from  the  deceased  parent  and  the  pre-­‐existing  heirs’  right  to  

receive   their   deceased   parent's   property.   The   courts   are   sympathetic   to   both  

parties.  The   case   law   shows   that   the   courts   can  be   torn  between   recognizing   that  

posthumously   born   children   deserve   "all   the   love,   respect,   dignity,   and   legal  

protection"  that  other  children  receive,  and  recognizing  that  estates  cannot  remain  

open  indefinitely.140  

  PMGR   and   PVSGR   have   the   potential   to   destroy   the   thousands   year   old  

process  of  determining  one's  heirs.141  Traditionally,  the  process  to  determine  one's  

heirs   was   fairly   straightforward.   The   female's   heirs   were   determined   upon   her  

death  and  the  male's  were  determined  within  a  10-­‐month  period  after  his  death.  But  

gamete  retrieval  situations  introduce  the  possibility  that  one's  heirs  may  never  fully  

be  determined.   Some   states  have  begun  addressing   this  problem  while  others   are  

woefully  lagging.142  

  For   example,   as   noted   above,   North   Carolina   has   a   statute   that   "if   read  

strictly"  would  prevent  PM  conceived  children  from  inheriting  from  their  parent.143  

The   statute,   written   in   1959,   reads   "Lineal   descendants   and   other   relatives   of   an  

                                                                                                               139  Ohl,  1997.        140  In  re  Estate  of  Kolacy  at  1263.  141  Carpenter,  2012.  142  Id.    143  Id.    

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intestate  born  within  10  lunar  months  after  the  death  of  the  intestate,  shall  inherit  

as   if   they  had  been  born   in   the   lifetime  of   the   intestate   and  had   survived  him."144    

Postmortem   born   children   exist   in   a   legal   limbo   between   being   classified   as  

illegitimate   and   being   classified   as   the   decedent's   heir.     This   has   led   several  

commentators   to   conclude   that   legislation   directly   addressing   the   rights   of  

posthumous  born  children  needs  to  be  enacted.145    

 

E.  Case  Law  Addressing  the  Issue  of  Consent  

  Most   of   the   cases   involving   issues   that   are   analogous   those   arising   from  

PMGR  and  PVSGR  do  not  directly  address  the  issue  of  how  the  decedent's  consent  to  

procreate   after   death   can   be   proven.   However,   some   generalization   can   be  made  

from  the  current  case  law.  The  current  case  law  addressing  the  broader  issue  of  PM  

conception  suggests  that  most  courts  will  strive  to  honor  the  reproductive  choices  

of   the   deceased   individual.   The   courts   will   try   to   discern   whether   the   deceased  

individual   intended   or   consented   to   procreate   posthumously.   If   the   decedent's  

intent   cannot   be   clearly   discerned,   the   courts   tend   to   not   allow   the   posthumous  

procreation.      

  Some  of  the  case  law  supports  that  explicit  written  patient  consent  to  PMGR  

or  PVSGR  should  be  honored  and  that  silence  should  not  necessarily  be  construed  as  

intent.  For  example,   in  Hecht,   the  decedent  had  given  his  explicit   consent   through  

multiple  written  documents  expressing  his  intent  for  his  girlfriend  to  use  his  sperm  

after  he  died.   If   the  Hecht   case  were  used  as   the  basis  of   implementing  a  hospital                                                                                                                  144  N.C.  Gen.  Stat.  §  29-­‐9;    145  Elliot,  2004;  Katz,  2006.  

  46  

PMGR   and   PVSGR   policy,   then   the   policy   would   need   to   focus   on   the   deceased  

patient's  intent  to  procreate  posthumously.    

  Although   the   case   law   emphasizes   the   deceased's   intent   to   procreate  

posthumously,   the   case   law   does   not   clearly   answer   what   type   of   consent  

adequately  shows  the  patient's  intent,  i.e.  explicitly  written,  explicitly  stated  or  what  

the   patient   would   have   wanted.   Instead,   the   cases   require   that   the   decedent's  

"actual   intention,"146  the   decedent's   “unequivocal   intention"147  or   the   decedent's  

"true   intention"148  be   proven   before   the   deceased   individual's   gametes   are   to   be  

used.   In   Woodward   v.   Commissioner   of   Social   Security,   the   court   required   the  

deceased's   pre-­‐mortem   consent   to   be   "clear   and   unequivocal"   and   stated   that  

"silence   or   equivocal   indications   of   a   desire   to   parent   posthumously"   did   not  

constitute  consent.149  While  all  of  these  intent  requirements  are  vague  standards  for  

determining  consent,  hospital  policies  requiring  explicit  written  consent  appear   to  

satisfy  the  intent  standards  used  by  the  courts.        

  Current   case   law  has   provided   some   answers   to   the   concerns   arising   from  

PMGR  and  PVSGR.  For  example,  the  Court  has  determined  that  the  U.S.  Constitution  

contains  an  implied  right  to  procreate.  In  Hecht,  the  court  determined  that  requests  

to   receive   pre-­‐mortem   stored   gametes   did   not   violate   public   policy   and   that   the  

deceased  have   the   right   to   control   the  disposition  of   their   gametes.   In  Capato,   the  

Supreme  Court   held   that   the   Social   Security  Administration  may   look   at   the   state  

intestacy  laws  of  the  deceased  individual  to  determine  survivor  benefits.    

                                                                                                               146  Hecht  v.  Superior  Court  at  851.  147  Id  at  857.  148  AZ  v.  BZ  at  158-­‐59.  149  Williams,  2011,  at  FN.  39.  

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  Although   case   law   has   provided   some   answers,   the   courts   can   only   do   so  

much.  They  are  limited  because  they  "can  only  address  the  specific  circumstances  of  

each   [PMGR   and   PVSGR]   controversy   that   presents   itself."150  Instead   PMGR   and  

PVSGR  concerns  may  be  better  addressed  by  "a  comprehensive  response  reflecting  

the  considered  will  of  the  people."151  What  this  comprehensive  response  would  look  

like  is  largely  outside  the  scope  of  this  thesis,  but  I  believe  that  hospital  PMGR  and  

PVSGR  policies  play  a  crucial  role  in  this  response.    

 

   

                                                                                                               150  Woodward  v.  Commissioner  of  Social  Security  at  557.  151  Id.  

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CHAPTER  4:  SOCIAL  POLICY  AND  PRACTICAL  CONSIDERATIONS  

 

  There  are  at  least  three  overarching  social  policies  implicated  by  PMGR  and  

PVSGR.  The  first  social  policy  encourages  the  respectful  treatment  of  the  dead.  The  

second  social  policy  encourages  the  protection  of  children's  welfare.  The  third  social  

policy  encourages  organ  donation,  from  the  deceased  and  living.  In  addition  to  social  

considerations,  the  practical  considerations  of  PMGR  and  PVSGR  must  be  addressed.    

 

A.  Respect  for  the  Dead  

  There  appears  to  be  a  "near  universal  respect  for  the  dead  body"  and  a  deep  

"innate   [human]  drive   to  recover  bodies  so   they  may  be  given  a  proper  burial."152  

The  courts   in   the  U.S.  have  created  special  quasi  property   rights   (discussed   in   the  

previous   chapter)   in   dead   bodies.   These   special   property   rights   recognize   that  

"indignities  to  the  human  body  may  violate  the...well-­‐being  of  the  deceased's  kin."153  

In  addition,  quasi  property  rights  grant  the  deceased's  family  the  right  to  sue  for  any  

unauthorized   mutilation   of   the   dead,   any   unauthorized   autopsy,   and   a   right   to  

control  the  deceased's  remains  when  the  deceased  is  silent  on  the  matter.154  

  While   "the   dead   are   not   usually   thought   of   as   having   rights   that   survive  

death...procreative   rights"   may   be   the   exception. 155  Our   society   has   placed  

importance   on   honoring   the   wishes   of   the   dead,   often   thinking   of   the   dead   as  

                                                                                                               152  Orr,  2002,  at  300,  301.  153  Schiff,  1997,  at  926.  154  Id.    155  Katz,  2006,  at  311.  

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something  other  than  a  corpse.156  The  argument  against  PMGR  and  PVSGR  is  that  we  

as  a  society  respect   the  dead  and  should  not  violate   this  policy  by  allowing  PM  or  

PVS  retrievals.    The  deceased  can  be  disrespected  by  PMGR  in  two  ways.  The  first  is  

if   the  PMGR  procedures  result   in  unnecessary  physical  violation  of   the  dead  body.  

For   example,   an   unnecessary   physical   violation   can   occur   if   the   body   is  

unnecessarily  mutilated  to  retrieve  the  gametes.  The  chosen  method  of  PMGR  may  

raise  issues  about  the  respectful  treatment  of  deceased  patients.157    

  Some   argue   that   PMGR   procedures   should   be   allowed   because   they   are  

analogous   to   autopsies.   Although   it   may   be   true   that   autopsies   mutilate   corpses  

more   than   PMGR,   the   two   procedures   enjoy   different   levels   of   public   approval.    

Autopsies   are  widely   accepted  by   society   as   a   permissible   violation   of   the   human  

body.158  We,  as  a  society,  allow  autopsies  to  be  performed  because  we  recognize  the  

good   that  may   result   from   the   autopsy.   Gamete   retrievals,   on   the   other   hand,   are  

probably  not  widely  accepted  by  society  as  a  permissible  violation  of  the  dead.  

  Another   way   the   dead   can   be   disrespected   is   if   PMGR   is   used   to   rush  

procreation   in   an   attempt   to   relieve   an   intimate   partner's   (or   family   member's)  

grief.  As  discussed  in  Chapter  2,  using  PMGR  to  relieve  grief  should  not  be  allowed  

unless  it  is  accompanied  by  the  deceased's  explicit  consent.  In  at  least  one  hospital,  

evidence   shows   that  many   retrieved  gametes  are  not  used.159  The   requestors  may  

think  PMGR  or  PVSGR  is  a  good  idea  at  the  time  because  the  requestor  may  want  to  

use  the  gametes  in  the  future  to  conceive  a  child.  However,  if  the  requestor  "decides  

                                                                                                               156  Id.  at  312.  157  Orr,  2010,  at  299.  158  Id.  at  300.  159  NY  Hospital  Guidelines  .  

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not  to  use  the  [gametes]  to  conceive  a  child  [the  corpse]  would  have  been  violated  

for  no  other  reason  than  to  give  [the  requestor]  reproductive  peace  of  mind."160    

     

B.  The  Welfare  of  the  Prospective  Child  

  The  policy  argument  that  receives  the  most  attention  stems  from  concern  for  

the   wellbeing   of   the   resulting   PM   or   PVS   born   child.   In   the   U.S.   there   is   an  

"overriding   legislative   concern   to   promote   the   best   interests   of   children."161  The  

courts  have  a  history  of  protecting  minor  children  from  harm.162  Many  people  have  

argued   that   society   is   harming   the   child   to   be   by   allowing   PMGR   and   PVSGR   to  

occur.  According  to  this  argument,  posthumous  and  PVS  procreation  will  harm  the  

child  because  the  child  will  only  have  one  parent.  One  commentator  asserts  that  the  

most  important  type  of  parents  a  child  can  have  are  "social  parents."163  She  argues  

that   children  need   parents  who  will   be   committed   to   raising   the   child.   Therefore,  

PMGR  and  PVSGR  should  not  be  allowed  unless  the  individual's  consent  "meets  the  

test  of  absolute  certainty"  because  PMGR  and  PVSGR  ensures  that   the  deceased  or  

PVS  individual  will  "not  be  available  to  be  an  actual  or  social  parent."164  While  I  do  

believe   that   single   parents   can   raise   their   children   just   as   well   as   two   parents,   I  

question  whether   a   parent   is   fulfilling  his   or   her   role   as   a   parent  when  he  or   she  

agrees   to   PMGR   or   PVSGR,   thereby   intentionally   choosing   not   to   be   a   part   of   the  

child's  life.                                                                                                                  160  Williams,  2010,  at  197.    161  Woodward  v.  Commissioner  of  Social  Security  at  546.  162  Id.  ("The  protection  of  minor  children,  most  especially  those  who  may  be  stigmatized  by  their  `illegitimate'  status  ...  has  been  a  hallmark  of  legislative  action  and  of  the  jurisprudence  of  this  court.")  163  White,  1999,  at  360.  164  Id.  

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  Another  argument  is  that  the  PMGR  or  PVSGR  born  child  is  harmed  because  

he  or  she  will  suffer  knowing  that  they  were  born  through  nontraditional  methods.  

While  it  is  true  that  we  may  not  fully  understand  the  psychosocial  effect  PMGR  and  

PVSGR   has   on   children,   it   is   unreasonable   to   assume   that   all   children   born   from  

these   methods   suffer   and   are   harmed.   In   addition,   the   argument   is   problematic  

because  without  this  type  of  procreation  the  child  would  never  have  been  born,  and  

the  life  of  the  child  is  a  net  benefit,  not  a  "harm".  Furthermore,  this  argument  fails  to  

take  into  consideration  the  benefits  the  child  will  experience.165  Whether  classifying  

the  effect  on  the  child  as  harm  or  not,  the  effect  PMGR  and  PVSGR  may  have  on  the  

child  should  be  considered.  

  One   child   welfare   argument   I   think   should   be   considered   and   that   is   of  

immediate   concern   is   that   a   PMGR   or   PVSGR   born   child   may   be   harmed   by   the  

current  ambiguity  in  the  law.  Although  some  state  legislatures  have  insisted  that  all  

children  will  be  "entitled  to  the  same  rights  and  protections  of  the  law"  regardless  of  

the  accidents  of  their  birth,  the  reality  (as  discussed  in  the  previous  chapter)  is  that  

PMGR  and  PVSGR  born  children  may  not  be  entitled  to  the  "financial  support  from  

their  parents  and  their  parents'  estates."166  If  a  child  is  born  into  the  world  without  

full   protection   and   benefits   of   the   law,   then   that   child   is   unfairly   being   denied  

opportunities   that   other   children   (conceived   through   traditional   means)  

automatically   receive.   This,   at   least   on   its   face,   seems   unjust   and   an   undesirable  

policy  to  advocate.  Legislation  is  probably  needed  to  address  this  concern,  although  

what  this  legislation  would  look  like  is  not  within  the  scope  of  this  thesis.                                                                                                                    165  Strong,  2006,  at  162.    166  Woodward  v.  Commissioner  of  Social  Security  at  546.  

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C.  Comparing  PMGR  and  PVSGR  to  Organ  Donations  

  A   tempting,   and   understandable,   argument   can   be   made   that   PMGR   and  

PVSGR  is  analogous  to  organ  donations  and,  therefore,  should  be  treated  the  same  

way.167  According   to   this  argument,   if  a  deceased  or  PVS   individual  has  previously  

consented   to   being   an   organ   donor   then   the   individual   can   be   said   to   have   also  

consented   to   PMGR   and   PVSGR.   Some   evidence   does   support   that   there   is   a  

"significant  association  between  supporting  posthumous  reproduction  and  being  an  

organ  donors."168  It  is  unclear  whether  organ  donors  also  support  PMGR  and  PVSGR.  

  In  some  ways  organ  donations  and  gamete  retrievals  are  very  similar.  Both  

procedures  are  highly   intrusive.  Both  procedures  are  performed  on   the   living  and  

dead.   Both   procedures   involve   taking   tissue   from   one   person   and   giving   it   to  

another  person.  However,  just  because  organ  donations  and  gamete  retrievals  may  

appear   analogous   does   not   mean   that   the   two   procedures   should   be   treated   the  

same  way.    

  I   think   that   it   is   a   leap   to   assume   that   consent   to   organ   donation   can   be  

construed   as   consent   to   PMGR   and   PVSGR.   There   are   some   key   differences   that  

separate   gamete   retrievals   from   organ   donations.   First,   the   tissue   transferred   in  

organ  donations  is  different  from  the  tissue  transferred  in  gamete  retrievals.  Organs  

have  already  come  into  being  and  no  longer  have  the  potential  of  being  something  

                                                                                                               167  Ohl,  1997,  at  893.  168  Barton,  2012,  at  739.  

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else.   Gametes,   in   contrast,   can   be   used   to   produce   a   new   human   being;   they   are  

rudimentary  building  blocks  that  represent  "the  ultimate  in...potentiality."169    

  Second,   organ   donation's   goals   are   different   from   gamete   retrieval's   goals.  

Some   goals   of   organ   donation   are   to   extend   a   recipient’s   life   or   to   increase   the  

overall  health  of  a  recipient.  In  contrast,  the  goal  of  PMGR  and  PVSGR  is  to  create  a  

new  PM  or  PVS  born  child.  Third,   the   level  of  responsibility  owed  to   the  retrieved  

materials   is   different.   Organ   donors   owe   no   legal   or  moral   responsibility   to   their  

donated   organs.   In   contrast,   "there   is   a...great   responsibility"   owed   to   children  

created  from  PMGR  and  PVSGR.170  Fourth,  the  consequences  of  the  organ  donation  

and   gamete   retrievals   are   different.   An   organ   donation   has   "very   little   ongoing  

consequence   to   deceased   [individuals]   or   their   family."171  In   contrast,   gamete  

retrievals   can   have   "major   consequences"   for   deceased   individuals   and   their  

families. 172  Gamete   retrieval   and   subsequent   procreation   "is   central   to   an  

individual's  identity  in  a  way  that  organ  donation  is  not."173    

 

D.  Practical  Considerations  

  So   far,   this   thesis   has   only   addressed   the   ethical,   legal,   and   social   policy  

aspects   of   PMGR   and   PVSGR.   However,   there   are   also   some   important   practical  

considerations  that  arise  from  PMGR  and  PVSGR.  The  practical  considerations,  while  

widespread,   are   best   discussed   in   the   hospital   setting   because   hospitals   are  

                                                                                                               169  Schiff,  1997,  at  919  (quoting  Kass  v.  Kass).    170  Ohl,  1996,  at  893.  171  Orr,  2010,  at  301.  172  Id.    173  Bahadur,  2002,  at  2773.  

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organizations   directly   affected   by   PMGR   and   PVSGR.   As   hospitals   have   begun  

implementing   PMGR   and   PVSGR   policies   that   address   these   concerns,   they   have  

been  forced  to  address  the  practical  considerations  of  the  PMGR  and  PVSGR.    

  The  practical  considerations  include  operational  issues  such  as:  feasibility  of  

the   retrievals,   the   costs   associated   with   the   retrievals,   managing   the   differing  

medical  team  opinions,  and  the  proper  role  hospitals  should  play  in  the  procedures.    

  Hospitals  are  concerned  with  providing  excellent  health  care  services  to  the  

public.   This   goal   has   two   components:   the   medical   component   and   the   business  

component.   Both  must   be   addressed   if   a   hospital   hopes   to   provide   and   continue  

providing   excellent   care.   Therefore,   the   pragmatic   business   side   of   PMGR   and  

PVSGR  should  not  be  dismissed.    

  As   a   business,   hospitals   strive   to   run   a   smooth   and   efficient   health   care  

operation.   For   example,   one   of   Wake   Forest   Baptist   Medical   Center's   goals   is   to  

promote   "operational   effectiveness." 174  Duke   University   Hospital   emphasizes  

teamwork  to  "achieve  common  goals."175  The  University  of  North  Carolina  Hospitals  

is  dedicated  to  creating  a  "system  of  care   that   is  efficient,  of  high  quality,  safe  and  

easy  to  navigate."176  To  have  these  goals  is  one  thing  but  to  actually  achieve  them  is  

entirely  different.  Hospitals  are  extremely  complex  businesses.  Policies  can  be  used  

to   guide   organizational   behavior   and   alleviate   some   of   the   confusion   and  

inconsistencies  that  commonly  plague  hospitals.  

                                                                                                               174  WFBMC  Mission  Statement.  175  Duke  Hospital  Mission  Statement.  176  UNC  Hospital  Mission  Statement.  

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  Hospitals   employ   large   numbers   of   health   care   professionals,   and   these  

professionals  may  have  varying,  or  conflicting,  opinions  about  the  permissibility  of  

PMGR  and  PVSGR.  Some  physicians  believe  that  the  very  idea  of  PMGR  and  PVSGR  is  

absurd;   others   believe   that   the   procedures   merit   serious   consideration.   If   the  

ultimate   decision   whether   to   honor   PMGR   and   PVSGR   requests   is   left   up   to   the  

physicians  receiving  the  requests,  and  the  hospital  has  not   issued  any  guidance  on  

how   the   physicians   should   decide,   then   factually   identical   PMGR   and   PVSGR  

requests   received   on   different   days   may   be   treated   differently.   This   inconsistent  

decision-­‐making   is   inefficient   because   it   leads   to   confusion   among   employees.   In  

addition,   inconsistent   decision-­‐making   may   reflect   poorly   on   the   hospital   if   the  

physicians'   decisions   are   contrary   to   the   hospital's   general   goals   and   image.  

Furthermore,  it  may  expose  the  hospital  to  unanticipated  litigation.177    

  To   avoid   inconsistent   responses   to   similar   PMGR   and   PVSGR   requests,  

hospitals  must  ensure  that  their  staff  is  fully  informed  as  to  how  they  expect  PMGR  

and  PVSGR  requests  will  be  handled  and  decided.  This  goal  can  be  accomplished  by  

implementing  a  PMGR  and  PVSGR  hospital  policy.  Like  most  hospital  policies,  PMGR  

and   PVSGR   policies   should   be   designed   to   provide   hospital   employees   with   a  

decision-­‐making  framework.  

  Another   practical   matter   hospitals   need   to   be   concerned   with   is   the   costs  

associated  with  PMGR  and  PVSGR,  i.e.,  gamete  retrieval  costs,  storage  costs,  and  the  

                                                                                                               177  I  am  assuming  here  that  hospital  policies  can  be  used  to  guide  behavior,  thus  making  it  more  predictable.  The  hospital  can  issue  a  policy  and  reasonably  assume  that  their  employees  are  following  the  guidelines  contained  in  the  policy.  Hospitals  can  look  at  their  policy  and  identify  what  part  of  that  policy  may  lead  to  litigation.  In  contrast,  when  hospitals  do  not  have  a  policy  they  may  have  no  idea  what  certain  employees  are  doing  and  cannot  predict  with  reasonable  certainty  problem  areas.  

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ART  costs.  This  whole  process  can  cost  "several  thousands  of  dollars."178  Insurance  

will  probably  not  cover  these  costs,  so  the  requestor  will  pay  out  of  pocket.179  The  

hospital   needs   to   make   sure   that   it   is   able   to   secure   reimbursement   for   the  

procedures.  Implementing  a  PMGR  and  PVSGR  policy  requiring  the  gamete  retrieval  

requestor  to  arrange  for  and  pay  for  all  the  services  ensures  that  the  hospital  does  

have  to  pay  for  the  services.      

  Hospitals  must  also  determine  whether  they  can  feasibly  comply  with  PMGR  

and   PVSGR   requests.   If   a   hospital   does   not   have   the   technology   or   specialists   to  

perform  a  PMGR  and  PVSGR  then  they  must  deny  all  such  requests  or   figure  out  a  

way  to  honor  future  requests.180  In  addition,  hospitals  must  determine  what  medical  

retrieval   techniques  will   be  used   and   if   they   can   safely   and   effectively  deliver   the  

retrieved  gametes   to  a  storage   facility.  PMGR  and  PVSGR  are  not  easily  performed  

and  require  special  equipment.  Also,  the  hospital  must  determine  whether  they  have  

the  appropriate  staff  to  comply  with  requests.  Often,  the  medical  team  is  made  up  of  

specialists.   These   specialists  must   be   readily   available   because   PMGR  must   occur  

within  a  short  window  of  time.  Hospitals  must  design  policies  that  take  into  account  

all  of  these  practical  considerations.  

 

   

                                                                                                               178  Soules,  1999,  at  363.  179  Id.  180  Id.  

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CHAPTER  5:  HOSPITAL  PMGR  AND  PVSGR  POLICIES  

 

  This  chapter  is  intended  to  demonstrate  how  hospital  policies  respond  to  the  

complex   ethical,   legal,   social,   and   practical   considerations   arising   from  PMGR   and  

PVSGR.  There   are   at   least   two  ways  hospital   policies   approach  PMGR  and  PVSGR.  

The   policies   can   restrict   PMGR   and   PVSGR   or   they   can   permit   PMGR   and   PVSGR.  

Restrictive  policies  make  honoring  PMGR  and  PVSGR   requests   and/or   subsequent  

use  less   likely,  while  permissive  policies  make  honoring  PMGR  and  PVSGR  request  

and/or  subsequent  use  more  likely.    

  Evidence   shows   that   even  permissive  policies   reduce   the  number  of   PMGR  

and   PVSGR   requests   honored.181  Therefore,   the   analysis   between   permissive   and  

restrictive   approaches   is   not  whether   a   policy   reduces   the   likelihood   of   honoring  

PMGR   and   PVSGR,   but   how   likely   a   policy   is   to   reduce   PMGR   and   PVSGR   as  

compared  to  another  policy.  So,  while  permissive  policies  reduce  PMGR  and  PVSGR,  

restrictive  policies  most  likely  further  reduce  the  number  of  requests.    

  Many  PMGR  and  PVSGR  policies  may  be  considered  restrictive  if  they  require  

the   hospital   to   reject   PMGR   or   PVSGR   requests   according   to   certain   exclusion  

criteria   contained   in   the   policy   (e.g.,   requestor   exclusions,   recipient/requestor  

exclusions,   time   exclusions,   etc.)   Permissive   policies   often   contain   some   of   these  

exclusions,   but   these   exclusions   are   either   not   as   numerous   or   they   are   less  

demanding  than  those  contained  in  restrictive  policies.    

                                                                                                               181  Tash  et  al.,  2003.    

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    Different   hospitals   often   take   different   approaches   when   drafting   their  

exclusion  criteria.  This  chapter  presents  and  analyzes  the  exclusion  criteria  used  by  

eleven   hospitals.182     A   table   of   the   exclusion   criteria   of   these   eleven   hospitals   is  

provided   at   the   end   of   this   thesis.183  The   number   of   exclusion   criteria   and/or   the  

burden   of   these   criteria   clearly   make   some   of   these   hospital   PMGR   and   PVSGR  

policies  more  restrictive  than  the  other  policies.  These  identified  exclusion  criteria  

are  then  analyzed  according  to  how  they  address  the  ethical,  legal,  social  policy,  and  

practical  considerations  arising  from  PMGR  and  PVSGR.  

 

A.  Restrictive  and  Permissive  Policy  Approaches    

  Hospital   policies   addressing   PMGR   and   PVSGR   generally   take   one   of   two  

approaches:   a   restrictive   approach   or   a   permissive   approach.   The   terms  

"restrictive"   and   "permissive"   should   not   be   understood   as   "unconditionally  

restrictive"   or   "unconditionally   permissive."   An   unconditionally   restrictive   policy  

would  never  honor  a  gamete  retrieval  request.  Unconditionally  restrictive  policies  at  

the  hospital  level  are  probably  informal,  unwritten,  and  therefore  undocumented.184  

Some   countries   have   adopted   nationwide   these   policies   and   completely   prohibit  

                                                                                                               182  I  have  collected  policies,  draft  policies  or  received  responses  about  their  policies  from  the  following:  Arkansas  Children's  Hospital  ("Arkansas"),  The  University  of  Virginia  ("Virginia"),  The  University  of  North  Carolina  Hospital  ("UNC"),  Duke,  Tuft's  Lahey  Clinic  ("Lahey  Clinic"),  East  Carolina  University's  Brody  School  of  Medicine  and  Pitt  County  Memorial  Hospital  ("ECU"),  Northwestern  Memorial  Hospital  ("Northwestern"),  Oregon,  Wake  Forest  Baptist  Medical  Center  ("WFBMC"),  Cornell's  NY  Hospital  Guidelines  ("New  York  Guidelines"),  Oregon  Health  and  Science  University  ("Oregon"),  and  the  University  of  Washington  Hospital  ("Washington").  183  See  Appendix  I.    184  I  found  no  discussion  of  hospitals  that  have  a  completely  restrictive  policy.  From  my  correspondence  with  various  hospitals  I  have  determined  that  a  completely  restrictive  policy  will  probably  be  unwritten.  I  can  only  guess  at  the  reasons  but  these  policies  may  be  unwritten  to  not  draw  attention  to  them.    

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PMGR   and   PVSGR.185  Unconditionally   restrictive   policies   raise   serious   questions  

about   patients'   autonomy   and   reproductive   freedom.   As   addressed   in   Chapter   2,  

there   are   valid   reasons   why   PMGR   and   PVSGR   procedures   should   be   allowed   in  

specific  circumstances.    

  In   contrast,   an   unconditionally   permissive   policy  would   honor   all   requests  

made.   Few   commentators   have   argued   for   a   completely   permissive   approach.186  

This   approach   also   raises   serious   questions   about   the   importance   of   patient  

autonomy  because  it  would  allow  another  party  to  make  PMGR  and  PVSGR  requests  

regardless  of  the  deceased  or  PVS  patient's  wishes.  

  The  restrictive  approach  and   the  permissive  approach  can  be   thought  of  as  

existing  along  a  sliding  scale.  On  this  sliding  scale,  a  restrictive  policy  may  decrease  

the   likelihood   that  PMGR  or  PVSGR  procedures   are  performed  while   a  permissive  

policy  may  increase  the  likelihood  that  PMGR  or  PVSGR  procedures  are  performed.  

Even  permissive  PMGR  or  PVSGR  policies  may  "dramatically  reduce  the  number  of  

[procedures]   performed."187  Many   hospital   policies   will   probably   contain   certain  

types  of  exclusions  that  may  reduce  the  number  of  honored  requests  or  subsequent  

use  of  retrieved  gametes.  Some  common  types  of  exclusions  seen  in  hospital  policies  

are:   consent   exclusions,   requestor   exclusions,   time   exclusions,   and   economic  

exclusions.188    

  Both   restrictive   policies   and   permissive   policies   claim   to   honor   patient  

                                                                                                               185  Epker  et  al.,  2012,  at  1072.  186  Katz,  2006,  at  302.  187  Id.  at  301  188  See  Appendix  I.    

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autonomy  by  doing  what  the  patient  wanted.  However,  the  two  approaches  disagree  

over  how  patients'  autonomy  is  sufficiently  protected.  

  PMGR   and   PVSGR   policies   drafted   using   the   restrictive   approach   often  

require   the   patient   to   explicitly   consent   to   PMGR   and   PVSGR   before   dying   or  

entering  PVS.  In  addition,  it  is  common  for  restrictive  policies  to  require  the  patient  

to  identify  who  is  authorized  to  use  the  retrieved  gametes.  Some  restrictive  policies  

assert   that   the  patient's  autonomy   is  promoted   through   the  patient's  pre-­‐death  or  

pre-­‐PVS  consent.  The  restrictive  approach  places  the  burden  on  the  deceased  or  PVS  

patient   to   opt   in   to   the   procedure   by  making   his   or   her  wishes   to   have   PMGR   or  

PVSGR   explicitly   or   clearly   known.189  If   the   patient   was   silent   on   the   matter,   the  

silence   is   construed  as  a   choice   to  not  have  PMGR  and  PVSGR.  Restrictive  policies  

may   "give   absolute   preference"   to   the   patient's   explicit   directions   and   limits   the  

surrogate  decision  maker's  power  to  consent  to  PMGR  or  PVSGR.  

  Permissive  policies  recognize  that  some  unwritten  evidence  may  adequately  

indicate   the   patient's   wishes   for   PMGR   and   PVSGR.   Permissive   policies   recognize  

that   relying   on   evidence   presented   by   those   who   knew   the   patient's   desires   and  

wishes   could  honor   a  patient's  wish   for  PMGR  or  PVSGR,   even   though   the  patient  

has  not  provided  explicit  written  evidence  of  his  or  her  wishes.   If   the  patient  was  

silent   on   the   matter,   the   silence   does   not   necessarily   indicate   that   the   patient   is  

against  the  procedure  and  posthumous  creation.   Instead,  some  permissive  policies  

would   allow   the   surrogate   decision   maker   to   consent   using   the   substituted  

judgment   standard.   The   permissive   approach   places   the   burden   on   the   individual  

                                                                                                                 

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who   does   not   desire   posthumous   reproduction   to   opt   out   of   the   procedure   by  

making   his   or   her   wishes   not   to   have   a   PMGR   or   PVSGR   clearly   known.   The  

permissive   approach   usually   gives   the   surrogate   decision   maker   the   ability   to  

interpret  the  patient's  unwritten  wishes  or  use  substituted  judgment.    

  I  think  that  hospitals  with  permissive  policies  run  the  risk  of  engaging  in  "a  

great  deal  of  guesswork  in  determining  what  the  decedent  wanted."190  The  medical  

team  may  need  to  rely  heavily  on  evidence  of  the  patient's  wishes  that  is  "colored  by  

the   interests,   motivations,   and   purposes   of   those   who   are   seeking   to   use   the  

[gametes]."191  In   contrast,  while   a   restrictive  policy   that   requires  patients'  written  

explicit  patient  consent  to  PMGR  and  PVSGR  may  "ignore  the  desire  of  others,"  the  

approach   is   preferable   because   it   "has   the   virtue   of   a   bright   line   rule   and   avoids  

speculation   about   the   deceased's   intentions."192  This   bright   line   rule   can   "provide  

clarity  and  certainty"  to  medical  teams  who  receive  PMGR  or  PVSGR  requests.193  A  

restrictive   policy   may   be   the   only   surefire   way   to   respect   the   deceased   or   PVS  

patient's  autonomy  because  anything  beyond  the  patient's  explicit  written  consent  

would  "call  for  prescience  [decision-­‐making]  beyond  anyone's  abilities."194    

 

B.  Comparing  Hospital  Policies  Exclusion  Criteria195    

  All  the  policies  and  responses  I  reviewed  contain  some  type  of  exclusion  that  

may  prohibit  PMGR  or  PVSGR   in  certain   instances.  However,   just  because  a  policy  

                                                                                                               190  Katz,  2006,  at  304.  191  White,  1999,  at  359-­‐60.  192  Katz,  2006,  at  307.  193  Id.  at  316.  194  Id.  195  See  Appendix  I.    

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contains   a   type   of   exclusion   does   not   necessarily  mean   that   the   policy   should   be  

viewed  as  restrictive.  Several  of  the  policies  I  collected  are  clearly  more  permissive  

than   the   other   policies   even   though   they   contain   some   exclusions.   The   most  

common   types   of   exclusions   in   the   policies   collected   were:   consent   exclusions,  

requestor   exclusions,   time   exclusions,   economic   exclusions,   gender   exclusions,  

medical   team   exclusions,   and   disease   or   viability   exclusions.   Some   of   the   policies  

had  additional  requirements  that  may  affect  whether  a  PMGR  or  PVSGR  request   is  

honored  and  whether  the  gametes  are  used.    

 

Consent  Exclusions  

  The  most  obvious  exclusions  in  hospital  policies  are  the  consent  exclusions.  

The  policies  range  from  requiring  explicit  written  consent  by  the  patient  to  allowing  

a  legally  authorized  individual  to  make  treatment  decisions  on  behalf  of  the  patient.  

The   most   common   type   of   consent   required   by   the   policies   was   explicit   written  

patient   consent.   Six   of   the   policies   collected   clearly   indicated   that   only   explicit  

written   patient   consent   for   these   procedures   would   be   honored.196  Without   this  

consent,  PMGR  or  PVSGR  would  not  be  performed  absent  a  court  order.  One  policy  

generally   requires   explicit   consent   but   did   concede   the   possibility   that   other  

evidence  may  be  considered  in  rare  cases.197  Finally,  two  policies  give  preference  to  

the  patient's  written  consent,  but  allow  other  forms  of  consent  to  be  used  when  the  

                                                                                                               196  The  six  policies  are:  Arkansas,  Virginia,  UNC,  Lahey  Clinic,  ECU,  and  Washington.  In  addition,  Duke  may  not  even  perform  the  procedures.    197  Personal  communications  (Email  response  from  Northwestern  concerning  their  draft  policy).  

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patient's  wishes  are  not  written  or  unknown.198  

  Of  all  the  hospital  policies  I  analyzed,  Tufts  University's  Lahey  Clinic  has  the  

strongest   consent   exclusion   criteria.   Lahey's   policy   consists   of   a   two-­‐step   consent  

exclusionary  process.  First,  Lahey  requires  written  and  notarized  patient  consent  to  

PMGR   and   PVSGR.   Second,   Lahey   requires   another   person   to   authorize   the  

retrievals.  If  the  patient  dies,  the  patient's  next  of  kin  must  authorize  the  retrieval.  If  

the  patient   enters  PVS,   the  patient's   surrogate  decision  maker  must   authorize   the  

retrieval.   This   two-­‐step   consent   is   unique   and   probably   further   decreases   the  

likelihood  that  PMGR  and  PVSGR  requests  will  be  honored.  

  Some  of  the  consent  requirements  are  very  demanding  on  the  patient.  Both  

Arkansas   Children's   Hospital   and   the   University   of   Virginia   require   prior   written  

patient  consent   that  clearly   indicates   the  patient's  wishes.   In  addition,   the  consent  

must   be   signed,   witnessed   by   two   non-­‐interested   adults,   and   notarized.   The  

University   of   Virginia's   policy   additionally   requires   the   patient   to   state   his   or   her  

willingness  or  unwillingness  to  be  recognized  as  a  parent  of  the  children  born  from  

the  retrieved  gametes.      

  The   University   of   North   Carolina's   gamete   retrieval   consent   requirements  

are   less   demanding.   The   patient  must   execute   a  written   document   that   identifies  

who  is  allowed  to  consent  to  a  collection  request  and  the  document  must  authorize  

the  named  individual  to  use  the  collected  gametes.  East  Carolina  has  a  similar,  but  

unwritten  policy.  East  Carolina's  unwritten  policy  is  to  not  retrieve  gametes  unless  

the   patient   has   executed   an   advance   directive   allowing   for   the   procedure   after  

                                                                                                               198  The  two  policies  are:  Oregon  and  WFBMC.  

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death.  Duke  Hospital  does  not  have  a  policy  and   it   is  unclear  whether  the  hospital  

permits  PMGR  and  PVSGR.    

  Northwestern   University   is   currently   drafting   a   gamete   retrieval   policy.  

Northwestern's  policy  will  define  consent  more  broadly  than  the  above  policies.  In  

most   cases,   Northwestern   will   only   allow   PMGR   if   there   is   an   advance   written  

authorization   for   the   retrieval   by   the   patient.   However,   in   "only   extremely   rare  

circumstances"  Northwestern  will   look  at  "compelling  non-­‐written  evidence  of   the  

individual's  wishes."199    

  The  hospitals  with  the  least  exclusionary  consent  criteria  are  Oregon  Health  

and   Sciences   University,   NY   Hospital,   and   Wake   Forest   Baptist   Medical   Center.  

OHSU's   policy   allows   the   deceased   or   PVS   patient's   domestic   partner   to   request  

PMGR   if   the   partner   has   "clear   and   specific"   evidence   of   the   patient's   intent  

evidenced   "by   writing   or   verbal   expression."200  The   NY   Hospital   Guidelines   allow  

the   patient's   previous   actions   and   expressions   to   be   used   as   evidence   of   the  

patient's  intent  to  have  PMGR.      

  Wake   Forest   Baptist   Medical   Center's   draft   policy   appears   to   contain   the  

least   restrictive   consent   exclusion   criteria.   Wake   Forest's   policy   would   let   the  

"patient's   legally   authorized   representative"   consent   to   PMGR   or   PVSGR.201  The  

legal  representative  may  consider  the  "previously  expressed  wishes  of  the  patient"  

to  determine  whether  the  patient  wanted  PMGR  or  PVSGR.202  If  there  are  no  known  

previously  expressed  wishes,  then  the  representative  may  "rely  on  [his  or  her  own]  

                                                                                                               199  Personal  communications  (Quoting  an  email  response  I  received  from  Northwestern).    200  OHSU  Policy  201  Wake  Forest  Baptist  Medical  Center  Policy.  202  Id.  

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knowledge  of   the  patient's   beliefs,   values,   and  preferences"   to  determine  whether  

the  representative  should  consent  to  the  procedures.203  

 

Requestor  Exclusions  

  In   addition   to   consent   exclusions,   most   restrictive   policies   limit   who   may  

make  gamete  retrieval  requests  or  who  may  use  the  retrieved  gametes.  Many  of  the  

policies  that  require  explicit  writing  also  require  that  the  patient  indicate  in  writing  

the   person   who   may   request   and   receive   their   gametes.   For   example,   Virginia,  

Carolina,  and  Lahey  all  require  the  patient  to  name  the  individual  who  may  request  

and  receive  their  gametes.    

  Some  of   the  policies   further   limit   the  requestors   to  non-­‐biologically   related  

individuals.   For   example,   NY   Hospital,   the   University   of   Virginia   Health   Systems,  

Wake  Forest  Baptist  Medical  Center,  and  the  University  of  North  Carolina  Hospital  

all  limit  requestors  to  either  the  patient's  wife  or  intimate  partner.204    

  Other   policies   may   allow   patients'   family   members   to   make   PMGR   and  

PVSGR  requests.  Lahey,  East  Carolina,  and  Oregon  all  permit  patients'  parents  and  

other  family  members  to  make  a  request.  Lahey's  policy  allows  the  patient  to  name  

anyone  the  patient  wishes.205As  long  as  the  patient  explicitly  states  who  may  receive  

his   or   her   gametes,   Lahey   does   not   judge   the   appropriateness   of   the   chosen  

                                                                                                               203  Id.  204  Although,  Virginia  and  UNC  do  not  define  partner,  WFBMC's  draft  policy  does.  According  the  this  policy  an  intimate  partner  is  "a  person  who  has  a  long  term  sexual  or  romantic  relationship  with  the  patient,  including  a  spouse,  "common  law"  spouse,  fiancée,  or  partner  in  a  long-­‐term  same  sex  relationship."    205  Lahey  Policy  (States  that  no  judgment  will  be  made  as  to  who  was  named  as  the  recipient  identified  by  the  patient).  

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individual.206  ECU's   unwritten   policy   is   to   allow   "a   wife,   mother   or   girlfriend"   to  

make  a  PMGR  request.207    

 

Time  Exclusions  

  Time   exclusions   are   also   commonly   used   in   PMGR   and   PVSGR   hospital  

policies   and  may   reduce   the   likelihood  of   the  procedures.  There  are   two  different  

types  of  time  exclusions.  The  first  denies  PMGR  requests  made  past  a  specified  time.  

Some   hospital   policies   restrict   how   long   after   death   a   PMGR   procedure   may   be  

performed.  For  example,  both  Carolina  and  NY  Hospital  allow  retrievals  only  within  

a  24-­‐hour  period  from  the  time  of  the  patient's  death.  Restricting  retrievals  to  this  

window   of   opportunity   may   increase   the   viability   of   the   retrieved   gametes.  

However,  there  is  at   least  some  evidence  that  sperm  is  viable  beyond  this  24-­‐hour  

window.208  

  The  second  time  exclusion  prevents   the  retrieved  gametes   from  being  used  

until  a  certain  time.  Some  policies  may   impose  a  mandatory  waiting  period  before  

the   retrieved   gametes   may   be   used   for   procreative   purposes.   A   commonly   seen  

required  waiting  time  is  one  year.  Both  Virginia  and  Cornell  all  require  a  one-­‐year  

wait,   while   Carolina   recommends   a   1-­‐year   waiting   period.   Even   Oregon's   policy,  

which   is   one   of   the  more   permissive   policies,   requires   a   3-­‐month  waiting   period  

before  the  retrieved  gametes  may  be  used.  In  addition,  a  mandatory  waiting  period  

may   be   imposed   if   there   is   a   conflict   between   interested   parties;   some   policies  

                                                                                                               206  Lahey  Policy.  207  Personal  Communications  (Quoting  an  email  response  I  received  from  ECU  about  whether  they  have  a  PMGR  policy).  208  Shefi,  2006.  

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exclude  any  retrieved  gametes  from  being  used  until  the  conflict  is  resolved.  Lahey,  

Virginia,  and  Oregon  policies  all  have  conflict  resolution  exclusion  criteria.  

  Oregon's   policy   in   directed   donation   situations   is   to   retrieve   the   patient's  

gametes  and  then  hold  the  retrieved  gametes   for  a  maximum  of  72  hours  to  allow  

for   the   requestor   to   provide   evidence   of   the   written   directed   donation.   If   the  

evidence  cannot  be  provided,  the  hospital  will  destroy  the  gametes.  

 

Economic  and  Other  Exclusions  

  By   far,   the   most   prevalent   exclusion   among   all   the   policies   I   collected   is  

economic   exclusions.  Almost   all   of   the  policies   contain   criteria   requiring   someone  

other   than   the   hospital   to   pay   for   the   costs   associated  with   the   retrieval,   storage,  

and   use   of   the   gametes.   This   excludes   individuals   unable   to   afford   the   associated  

costs  from  successfully  requesting  PMGR  and  PVSGR.    

  Some   of   the   hospital   policies   either   require   or   encourage   the   individual  

making   the   request   to   go   through   counseling   before   using   the   retrieved   gametes.  

While   this  practice  may  not  necessarily  exclude  a  requestor   from  eventually  using  

the  retrieved  gametes,  the  end  result  may  be  to  discourage  the  requestor  from  using  

the   retrieved   gametes.   For   example,   one   hospital   discovered   that   "appropriately  

counseled  women...rarely  proceed  with  an  attempt  at  pregnancy."209    

  At  least  one  policy  excludes  the  PMGR  or  PVSGR  from  being  performed  if  the  

physicians   determine   that   the   patient's   condition   may   affect   the   viability   of   the  

                                                                                                               209  New  York  Guidelines.  

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gametes.210  Several  of  the  policies  allow  the  retrieved  gametes  to  be  excluded  from  

being  used  if  there  is  the  possibility  that  some  condition  or  disease  will  be  passed  on  

to  the  subsequent  child.211  

  Finally,   some   policies   exclude   PMGR   and   PVSGR   performance   based   on  

seemingly   arbitrary   criteria.   At   least   one   policy   prohibits   PMGR   or   PVSGR   if   the  

patient  was  not  the  clinic's  patient  before  dying  or  entering  PVS.212  Another  policy  

prohibits  PMGR  or  PVSGR  if  the  patient  is  not  a  resident  of  the  state.213  These  may  

have  been   included   to  address  some  valid  concerns  such  as  preventing  PMGR  and  

PVSGR  tourism  across  hospitals  and  states,  but  those  concerns  appear  remote  and  

highly  unlikely.    

 

C.  How  Hospital  Policies  Address  the  Concerns  of  PMGR  and  PVSGR  

  An  important  question  to  ask  is  whether  hospital  policies  are  addressing  the  

concerns   arising   from  PMGR   and   PVSGR.   The   analysis   below   is   intended   to   show  

how  certain  hospitals  treat  these  key  issues.  

     

Autonomy  

  The  hospital  policies   I   reviewed  all   appear   to  be  driven  by   the  overarching  

ethical   issues.  All   of   the  policies,  whether   restrictive  or  permissive,   are   concerned  

with  patient  autonomy,  beneficence,  and  nonmaleficence.  All  of  the  policies  appear  

to  indicate  that  there  are  some  reasons  to  support  procreation  after  death,  because  

                                                                                                               210  UNC  Policy.    211  UNC  Policy;  OHSU  Policy.  212  Lahey  Policy.    213  Arkansas  Policy.    

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they  all  allow  PMGR  and  PVSGR  in  at  least  some  instances.  

  Policies   can   address   the   issue   of   patient   autonomy   in   different   ways.  

Restrictive  policies  take  the  fact  finding  out  of  the  hospital's  hands  and  may  be  less  

burdensome   on   physicians,   because   they   would   not   need   to   speculate   whether  

PMGR  and  PVSGR  is  something  the  patient  wanted  or  would  have  wanted.  In  these  

policies,   the  patient   is   the  ultimate  decision  maker.  However,   the  patient  needs   to  

make   that   decision   before   dying   or   entering   PVS   because   the   restrictive   policies  

often  prevent  non-­‐explicit  evidence  from  being  used  to  show  the  patient’s  wishes  to  

have   PMGR   or   PVSGR.   Restrictive   policies,   like   the  University   of   North   Carolina’s,  

require   explicit   pre-­‐mortem  or   pre-­‐PVS  directives   permitting   the   procedure   to   be  

performed  and  designating  the  recipient  to  use  collected  gametes  gametes.  Some  of  

the   policies   may   impose   additional   consent   requirements   on   the   patients.   For  

example,  Virginia's  policy  requires  the  patient  to  consent  to  the  procedure  in  writing  

and  then  have  the  writing  witnessed  and  notarized.  This  may  be  asking  a   lot  of  an  

individual  who  does  not  normally  need  to  get  a  document  witnessed  and  notarized  

before  choosing  to  procreate.    

  Permissive  policies  may  encourage  patient  autonomy  but  in  a  different  way.  

Permissive   policies   allow   others   to   consent   to   PMGR   or   PVSGR   on   behalf   of   the  

patient.   For   example,  Wake   Forest's   draft   policy  would   allow   the   patient's   legally  

authorized  representative  to  make  the  PMGR  or  PVSGR  choice  for  the  patient.  Wake  

Forest's  policy  appears  to  recognize  that  it  may  be  unrealistic  to  require  individuals  

to  draft  written  documents   that   explicitly  make   their  wishes  of  PMGR  and  PVSGR  

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known.   Instead,  Wake   Forest   attempts   to   enable   the   patient’s   spouse   or   intimate  

partner  to  make  a  choice  based  on  the  patient's  life  statements  and  actions.    

  While   it  may  be   true   that  actions  and  past   statements   can  show  a  person's  

wishes,  I  question  whether  someone  else  can  recognize  the  crucial  past  actions  and  

properly  interpret  those  actions  to  reach  the  decision  the  patient  wanted  or  would  

have   made.   Evidence   suggests   that   patients   showing   such   a   strong   desire   to  

procreate   while   alive   may   lead   their   intimate   partner   to   incorrectly   assume   the  

patients  wishes  in  the  event  of  death  or  PVS.214  

  Some   policies   also   appear   conflicted   over   the   proper   treatment   of   patient  

autonomy.   For   example,   Lahey's   policy   appears   to   advocate   a   PMGR   and   PVSGR  

patient's  autonomous  choice  while  also   limiting  his  or  her  autonomous  choices.   In  

PMGR   and   PVSGR   situations,   the   Lahey   Clinic   requires   explicit   consent   by   the  

patient  before  PMGR  or  PVSGR  is  performed.  However,  the  policy  also  requires  the  

deceased's   next   of   kin   (in   PMGR   situations)   or   the   surrogate   decision   maker   (in  

PVSGR  situations)  to  authorize  the  procedures.  As  a  result,  it  appears  that,  at  least  in  

some  situations  (such  as  when  the  patient  and  partner  are  not  married),  the  Lahey  

Clinic   takes   away   the   patient   and   the   patient's   intimate   partner's   autonomous  

decision  to  create  a  PM  or  PVS  born  child  and  places  those  wishes   in  the  hands  of  

another  individual.    

 

Respect  for  the  Dead  

  The  University  of  North  Carolina's  policy  may  indicate  a  greater  concern  with                                                                                                                  214  Nakhuda,  2010,  at  1463-­‐64.  (Female  partners  accurately  predicted  their  male  partners’  preferences  79%  of  the  time,  whereas  the  male's  predictions  where  accurate  71%  of  the  time.)  

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the   respectful   treatment   of   the   dead   than   some   of   the   other   policies.   The   policy  

states  that  any  PMGR  or  PVSGR  request  may  be  rejected  if  the  "circumstances...affect  

the   efficacy   of   gamete   collection   or   use."215  It  may   be   a   stretch,   but   by   allowing   a  

denial  based  on  efficacy,  the  policy  appears  to  be  unwilling  to  unnecessarily  disturb  

the  deceased  or  PVS  patient's  bodies.216    

  Wake   Forest's   draft   policy   appears   to   be   concerned   with   how   arbitrarily  

performed  PMGR  and  PVSGR  procedures  may  show  a  lack  of  respect  for  the  dead  or  

PVS   patient.   WFU's   policy   requires   that   a   PMGR   or   PVSGR   procedure   to   be  

performed  if  the  "purpose  is  to  pursue  conception."217  This  suggests  that  WFU  will  

only   perform   the   procedure   if   there   is   a   reasonable   indication   that   the   requestor  

will   use   the   retrieved   gametes   to   reproduce.   By   requiring   a   purpose   before   the  

retrieval  is  performed,  WFU  appears  to  share  Cornell's  view  that  "retrievals  without  

likely   use...could   represent   mutilation   of   the   dead   that   may   represent   a   lack   of  

respect."218  

   

Treatment  of  Grief  

  Several  of  the  policies  acknowledge  the  effect  that  death  or  PVS  has  on  loved  

ones.  Wake  Forest   recognizes   that   the  death   of   a   loved  one  may  have   "significant  

physical,   psychosocial,   and   spiritual"   impact  on   the  patient's   intimate  partner   and  

other  family  members.  Wake  Forest's  policy  would  not  require  counseling  but  offer  

                                                                                                               215  University  of  North  Carolina  Policy.  216  Of  course  UNC's  policy  may  instead  be  stressing  beneficence  by  stressing  that  unnecessary,  and  potentially  expensive  treatment  will  not  be  performed  unless  UNC  can  reasonably  predict  a  beneficial  outcome.      217  Wake  Forest  Policy.  218  NY  Guidelines.  

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support  if  needed.  In  stark  contrast,  Virginia's  policy  requires  the  intended  recipient  

of   gametes   to   "[undergo]   at   least   two   sessions   with   a   psychologist   or  

psychiatrist."219  These   psychologist   or   psychiatrist   will   then   need   to   provide   "a  

statement   that   the   recipient   is   psychologically   prepared   to   undergo   [ART]  

procedures."220    

  Instead   of   requiring   counseling,   some   policies   recommend   or   require   a  

waiting  period.  It  is  unclear  how  long  it  takes  people  to  get  over  the  loss  of  a  loved  

one.   Often   the   grief   is   severe   and   clouds   judgment.   Evidence   suggests   that  many  

people  are  supportive  of  mandatory  waiting  periods,  but  are  against  ones  lasting  a  

year  or  more.  Possibly   in  an  attempt  to  prevent  grief-­‐influenced  gamete  recipients  

from   immediately   using   their   loved   one's   retrieved   gametes,   OHSU   Health   Care's  

policy   requires   a   three-­‐month   waiting   period   before   a   domestic   partner   can   use  

retrieved   gametes.     It   is   unclear  why   OHSU   chose   three  months   as   an   acceptable  

waiting  period,  or  how  this  requirement  is  enforced.      

     

Organ  Donation  vs.  Gamete  Retrieval  

  As  mentioned   in  Chapter  4,   some  evidence   suggests   that  many  people  who  

are  organ  donors  are  more  likely  to  support  PMGR  or  PVSGR.221  However,  it  would  

be  incorrect  to  assume  that  all  organ  donors  support  PMGR  and  PVSGR  and  believe  

that   consent   to   organ   donation   can   be   used   in   the   absence   of   a   deceased   or   PVS  

patient's   explicit   written   consent   to   PMGR   or   PVSGR.   Only   two   of   the   collected  

                                                                                                               219  Finnerty,  2002,  at  177.    220  Id.    221  Barton,  2012,  at  739.  

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policies   directly   address   the   issue   of   whether   consent   to   organ   donation   is  

indicative  of  the  patient's  desire  for  PMGR  and  PVSGR.    

  Oregon's  policy  directly  addresses  the  comparison  between  organ  donations  

and  gamete  retrievals.  Oregon's  policy  does  not  allow  general  organ  donation  cards  

or   registry   to   be   used   as   proof   that   a   deceased   individual   consents   to   a   PMGR  

procedure,  unless  the  card  or  registry  specifically  allows  the  patient's  gametes  to  be  

retrieved.  It  is  unclear  why  OHSU  included  this  provision  in  their  policy  when  most  

of   the  policies   collected  do  not   address   the   issue.  Oregon  may  be   responding   to   a  

recent  court  case  where  the  court  ruled  that  a  man's  consent  to  organ  donation  was  

sufficient  evidence  to  prove  that  he  consented  to  PMGR.222  

  The   New   York   Guidelines   also   directly   addresses   whether   organ   donation  

can  be  expanded  to  include  gamete  retrievals.  The  guidelines  recognize  that  PMGR  

is   "fundamentally   different   from   organ   donation."223  Therefore,   consent   to   organ  

donation  alone  cannot  be  used  as  proof   that   the  patient  wanted  to  procreate  after  

death.    

 

The  Child's  Welfare    

  The   concern   for   future   children   born   from   PMGR   and   PVSGR   may   be  

addressed   by   the   policies   that   contain   a   testing   requirement.   The   University   of  

North   Carolina's   policy   appears   concerned   that   a   patient's   pre-­‐existing   disease   or  

condition  may  be  passed  through  gamete  use  and  may  decline  performing  PMGR  or  

PVSGR   on   these   grounds.   It   is   unclear   whether   this   restriction   is   due   to   general                                                                                                                  222  Spielman,  2009.    223  New  York  Guidelines.  

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public  safety  concerns  or  out  of  concern  for  the  resulting  child.    

  None   of   the   collected   policies   directly   address   concern   for   a   child   being  

raised  in  a  single  household  or  the  effect  that  not  ever  meeting  one's  genetic  parent  

may  have  on  the  child.  This  is  understandable  as  these  child  welfare  arguments  are  

highly  speculative.    

  An  interesting  way  that  the  child's  welfare  can  be  addressed  is  found  in  the  

University   of   North   Carolina's   policy.     UNC   Hospitals   will   refer   their   PMGR   and  

PVSGR   requestors   to  UNC's   legal   department   for   "legal   advice   about   the   status   of  

offspring   conceived   by   [ART]"   before   the   requestor   is   allowed   to   use   retrieved  

gametes.224  As  previously  mentioned,  North  Carolina's  statute  does  not  recognize  a  

child   as   being   an   heir   of   the   deceased   parent   if   that   child   is   born  more   than   ten  

months   after   that   parent's   death.225  So   sending   the   intimate   partner   to   the   legal  

department   may   dissuade   those   determined   to   conceive   their   deceased   or   PVS  

partner's  child.    

 

Potential  Estate  Conflicts  

  Several  of  the  policies  appear  to  contain  provisions  that  could  minimize  the  

estate  problems  stemming  from  PMGR  and  PVSGR.  These  policies  state  that  if  there  

is  a  conflict  between  interested  parties  over  the  retrieved  gametes,  the  gametes  will  

be  stored  until  the  conflict  is  resolved.  The  effect  of  having  these  criteria  is  threefold.  

First,   hospitals   stay   out   of   the   legal   mess   (or   at   least   do   not   make   it   worse).  

Hospitals  will  hold  the  gametes  until  the  courts  tell  them  what  they  should  do  with                                                                                                                  224  UNC  policy.  225  N.C.  Gen.  Stat.  §  29-­‐9.  

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them.   Second,   requestors   are   comforted   by   the   retrieval   because   they   know   that  

they   still   have   a   chance   to   use   them.   Third,   the   living   heirs   have   peace   of   mind  

knowing  that  no  future  siblings  will  be  born  until  the  issue  is  resolved.  All  hospital  

policies  should  consider  including  statements  on  how  PMGR  will  be  handled  when  

there  is  a  conflict  over  the  retrieval  and  use.    

 

D.  Key  Concerns  Hospital  Policies  Need  to  Address  

  I   think   the   key   concerns   that   all   hospital   PMGR   and   PVSGR   policies   must  

address  are  deceased  or  PVS  patients'  autonomy  and  the  type  of  consent  needed  for  

PMGR  and  PVSGR.  All  of   the  other  concerns  are  secondary  to  this  one.   I   think  that  

policies   that   require   patients'   express   written   consent   for   PMGR   and   PVSGR   are  

superior  at  protecting  patients'  autonomy,  because  they  better  ensure  that  what  the  

patient  wants   is   actually  done.  Without   the  patient's   explicit  written  consent,   "the  

intentions   of   the   decedent   [and   PVS   patient]   can   only   be   the   subject   of  

speculation." 226  Hospital   policies   that   allow   explicit   non-­‐written   consent   or  

substituted   judgment   turn   the   medical   team   into   a   jury   that   must   weigh   the  

evidence  presented  to  them  by  the  requestor.  I  think  this  result  should  be  avoided.    

  The   literature   is  rampant  with  questionable  evidence  some  physicians  (and  

judges)   accept   as   indicative   of   the   deceased   or   PVS   patient’s   desire   for   PMGR   or  

PVSGR.   For   example,   one   physician   performed   a   PMGR   after   the   requestor  

presented   him   with   a   tape   of   the   deceased   patient   expressing   a   desire   to   have  

children.  This  was  the  only  evidence  presented.  I  fail  to  see  how  this  evidence  shows  

                                                                                                               226  Nakhuda,  2011,  at  1463.  

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the   patient’s   desire   to   father   children   posthumously.   In   another   case,   PMGR  was  

performed  after   the  deceased  patient's  mother  presented  evidence   to  a   court   that  

indicated  her  now  deceased  19-­‐year-­‐old  son  wanted  to  find  a  wife  and  start  a  family.  

The  evidence  she  used  to  support  her  claim  was  that  her  son  had  already  named  his  

three  future  children.  Once  again,  I  fail  to  see  how  this  type  of  evidence  sufficiently  

shows  the  patient's  consent  to  PMGR  or  PVSGR.    

  At  this  point  an  argument  is  often  made  that  surrogate  decision  makers  are  

allowed   to   make   these   decisions   in   other   medical   situations   based   on   what   the  

patient  wanted  or  based  on  substituted  judgment,  such  as  organ  donation  or  end  of  

life  decisions.  But  these  decisions  are  different  from  PMGR  and  PVSGR.  

  The  decision  to  pass  on  one's  own  genes  is  an  intimate  and  deeply  personal  

decision.  Although  many  people  procreate  by  accident  or  without   the   intention   to  

create   a   child,   they   cannot   claim   that   they  did   not   know   that   consequences   could  

result   from   copulation.   All   competent   mature   people   recognize,   at   least   on   some  

level,   that   engaging   in   sex   may   result   in   the   creation   of   a   child.   Whether   people  

accept  the  consequence  is  a  different  issue.  In  contrast,  in  PMGR  and  PVSGR,  another  

person   is  making  reproductive  decisions   for   the  deceased  or  PVS  patient.  Without  

express  consent,   the  patient  may  or  may  not  have  recognized  the  consequences  of  

the  act.    

  Besides   the   primary   concerns,   hospitals   should   address   several   other  

concerns   in   their   PMGR   and   PVSGR   policies.   I   think   that   the   following   concerns  

should   be   addressed,   regardless   of   whether   a   hospital   implements   a   permissive  

policy   or   a   restrictive   policy.   First,   PMGR   and   PVSGR   policies   should   address   the  

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retrieval,  storage,  and  subsequent  use  of  gametes.  The  hospital  must  determine  the  

level  of  involvement  it  is  willing  to  take.  Each  step  in  the  process  involves  different  

groups  of  individuals.  The  hospital  must  determine  whether  it  has  the  duty  to  set  up  

and  monitor  the  entire  process  or   if   that  duty  is  delegated  to  the  requestor.  PMGR  

and  PVSGR  policies  are  a  good  way  to  address  these  concerns.  Second,  every  policy  

should  address  the  costs  associated  with  PMGR  and  PVSGR.  Third,  until   legislation  

addresses  the  legal  status  of  children  born  posthumously,  PMGR  and  PVSGR  policies,  

should   attempt   to   mitigate   the   harm   caused   to   children   born   from   PMGR   and  

PVSGR.  I  think  this  could  be  achieved  by  referring  the  gamete  requestor  or  recipient  

to   the   hospital's   legal   department   so   that   the   requestor   is   aware   of   the   potential  

consequences  of  using  the  retrieved  gametes.    

 

     

   

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CHAPTER  6:  ALTERNATIVES  TO  HOSPITAL  POLICY  

 

  So   far   this   thesis  has   shown   the   complexity  of   the   ethical,   legal,   social,   and  

practical   concerns   arising   from   PMGR   and   PVSGR   procedures.   I   have   argued   that  

hospital  policies  can  be  (and  are)  used  to  address  the  concerns  arising  from  PMGR  

and  PVSGR.  This  thesis  would  be  incomplete  if  I  did  not  consider  some  alternatives  

that  could  be  used  to  address  the  ethical,  legal,  social,  and  practical  concerns  raised  

by  PMGR  and  PVSGR.  The  first  alternative  is  to  use  legislation  to  regulate  PMGR  and  

PVSGR.   The   second   alternative   is   to   use   professional   medical   organizations   to  

impose  guidelines  on  their  members.    

 

A.  Government  Legislation  Alternative  

  PMGR   and   PVSGR   are   not   just   a   concern   in   the   U.S.,   but   "appear   on   a  

worldwide   basis."227  Most   of   the   issues   raised   by   PMGR   and  PVSGR   are   universal.  

Assisted  reproduction  is  largely  unregulated  by  the  U.S.  government.  However,  this  

is  not   the  case  around  the  world.  As  a  matter  of   fact,  several  countries  around  the  

world  have  already  used  government  legislation  to  ban  or  limit  PMGR  and  PVSGR.    

  Several   countries   have   prohibited   PMGR   and   PVSGR   outright   through  

legislation.   Among   these   are   Canada,   Denmark,   France,   Germany,   Hungary,  

Netherlands,   Norway,   Slovenia,   and   Sweden.228  In   Hungary,   for   example,   the   law  

states   that   gametes   coming   from   a   dead   body   or   dead   fetus   cannot   be   used   for  

                                                                                                               227  Katz,  2006,  at  294.  228  Epker  et  al.,  2012,  at  1072.    

  79  

assisted  reproduction.229    

  Several  countries  have  used  legislation  to  limit  PMGR  and  PVSGR  requests.  In  

both  the  U.K.  and  the  Czech  Republic,  the  legislation  requires  that  PMGR  and  PVSGR  

patient  must  make  their  wishes  known  in  writing.230  In  the  Czech  Republic,  PMGR  is  

allowed   and   practiced.231  However,   children   born   from   these   means   are   not   the  

legal  heirs  of  the  decedent.232  In  Australia,  there  is  no  government  prohibition  but  a  

court  order  must  be  obtained.233  

  I   think   that  state   legislation  could  address   the  concerns  arising   from  PMRG  

and   PVSGR   just   as   well   as   hospital   policies.   However,   there   are   currently   some  

barriers   and   problems   with   using   legislation   that   make   hospital   policies   a   more  

suitable  way   to   address   the   concerns.   First,   using   state   legislation   to   address   the  

concerns  arising  from  PMGR  and  PVSGR  procedures  may  be  overkill.  Some  hospitals  

receive   a   few   requests   a   year,  while   other   hospitals   receive   a   few   requests   every  

couple  of  years.234  Some  hospitals  do  not  even  feel  that  the  issue  comes  up  enough  

to  draft  policies  on  the  matter.235  In  addition,  most  of  the  general  public  is  not  even  

aware   that   posthumous   reproduction   is   a   possibility,   much   less   PMGR   and  

PVSGR.236  The   concerns   of   PMGR   and   PVSGR   are   certainly   important,   but   it   is  

unclear  whether  PMGR  and  PVSGR  are  common  enough  to  warrant  legislation.  

                                                                                                               229  Dotsal,  2005,  at  2360.  230  Epker  et  al.,  2012,  at  1072.    231  Dotsal,  2005,  at  2360.    232  Id.    233  Epker,  2012,  at  1072.    234  Personal  Communications  with  Northwestern  Memorial  Hospital,  Wake  Forest  Baptist  Medical  Center,  and  the  Brody  School  of  Medicine.    235  Personal  Communications  with  Duke  and  ECU.  236  Barton,  2012,  at  739.  

  80  

  Second,   allowing   states   to   regulate   PMGR   and   PVSGR   procedures   could   be  

inconsistent   with   the   traditionally   held   (and   judicially   supported)   belief   that  

individuals  have  the  right  to  privacy,  which  includes  the  right  to  reproduce  (and  not  

reproduce).  State  legislation  on  PMGR  and  PVSGR  may  unnecessarily  intrude  on  this  

right.   Furthermore,   Americans   may   be   unwilling   to   let   their   states   make   their  

reproductive  decisions  for  them.237    

  Another   problem   with   using   government   legislation   is   the   complexity   of  

PMGR  and  PVSGR.  This  complexity  may  prevent  state  legislation  from  being  enacted  

for  some  time.  Already  at  least  one  restrictive  PMGR  bill  has  been  presented  before  

a  state  legislature  and  not  made  into  a  law.238  Adding  to  the  complexity  is  the  lack  of  

consensus  in  the  literature  on  the  type  of  consent  needed  for  PMGR  and  PVSGR.  It  is  

even   unclear   if   there   is   a   majority   on   the   issue   that   can   provide   guidance   to  

lawmakers.  

  Although  a  complete  analysis  of  how  state  legislatures  can  be  used  to  address  

the   concerns  arising   from  PMGR  and  PVSGR   is  not  within   the   scope  of   this   thesis,  

there  are  a   few  ways  that  state   legislation  could,  relatively  easily,  address  some  of  

the  concerns  created  by  PMGR  and  PVSGR.  First,  a  PMGR  and  PVSGR  option  can  be  

added  as  an  option  along  with  donor  registration.239  This  may  help  alleviate  some  of  

the  concerns  of  whether  the  deceased  or  PVS  patient  consented  to  PMGR  or  PVSGR.  

                                                                                                               237  Nakhuda,  2011,  at  1464;  Katz,  2006,  at  299.  238  Cohen,  1998.  239  Nakhuda,  2011,  at  1466.  

  81  

Second,  state  legislatures  could  amend  their  state's  advance  directive  legislation  to  

include  PMGR  and  PVSGR.240  

  Although   it   is   not   clear   to   me   whether   legislation   specifically   addressing  

PMGR  and  PVSGR  is  necessary  at  this  point  in  time,  I  do  think  that  state  legislation  

could  address  the  concerns  arising  from  PMGR  and  PVSGR.  Unfortunately,  I  do  not  

think  that  PMGR  and  PVSGR  legislation  will  be  implemented  within  the  foreseeable  

future.  So,  until  such  legislation  shows  promise,  hospital  PMGR  and  PVSGR  policies  

are  the  best  option  to  sufficiently  address  the  concerns  arising  from  the  procedures.  

PMGR   and   PVSGR   policies   can   then   be   used   as   stepping-­‐stone   if   it   is   later  

determined  that  we  need  a  bigger  and  better  solution  to  the  problems  of  PMGR  and  

PVSGR.      

     

B.  Professional  Medical  Organization  Alternative    

  A  second  alternative  to  using  hospital  policies  to  guide  decision-­‐making  is  to  

use  professional  organizations  to  guide  PMGR  and  PVSGR.    

  The  first  problem  with  this  alternative  is  that  it  has  already  been  done.  Using  

this  alternative  is  one  of  the  leading  causes  why  hospitals  have  begun  adopting  their  

own  policies.   In   1997,   the  American   Society   For  Reproductive  Medicine   ("ASRM")  

released  their  guidelines  on  the  issue.  Then  in  2004,  ASRM  released  another  set  of  

guidelines.  The  guidelines  allow  PMGR,  but  note  that  if  prior  consent  is  not  given  or  

the  patient's  wishes  are  not  known  then  the  medical  team  does  not  have  to  honor  a  

                                                                                                               240  Spielman,  2009,  at  339.  

  82  

request.241  The   guidelines   essentially   say   that   physicians   should   use   their   best  

judgment   and   provide   an   "[answer]   within   the   context   of   the   individual  

circumstances  and  applicable  state   laws."242  The  ASRM  guidelines  seem  to  indicate  

that  physicians  have  "no  ethical  duty  to  honor  the  request,  nor  is  denial  required."243  

  It   would   be   reasonable   to   assume   that   since   urologists   commonly   receive  

PMGR   and   PVSGR   requests,   their   professional   organization   would   have   issues  

guidelines  on  the  subject.  However,  the  American  Urologist  Association  ("AUA")  has  

yet   to  produce  guidelines   for   such   requests   and   retrievals.244  Instead,  members  of  

the  AUA  must  turn  to  the  AUA's  general  code  of  ethics,  which  require  urologists  to  

consider   the   "best   interests   of   the   individual,   of   society,   and   unforeseen  

consequences."245  The   problem   with   the   professional   organizations   is   that   they  

provide  little  (ASRM)  to  no  (AUA)  guidance  to  the  practicing  physicians  faced  with  

gamete  retrieval  requests.    

  Second,   professional   regulation   can   lead   to   inconsistent   treatment   of  

identical  cases.  Not  every  physician  is  part  of  a  professional  organization.  Therefore,  

hospitals   may   have   some   of   their   physicians   following   the   guidelines   and   other  

physicians   following   their   own   guidelines.   As   mentioned   in   Chapter   5,   hospitals  

have  an  interest  in  providing  their  patients  with  consistent  and  predictable  care.  If  

the  medical  teams  do  what  they  think  is  best,  their  opinions  and  beliefs  may  lead  to  

inconsistent  treatment  and  reflect  badly  on  the  hospital.    

                                                                                                               241  ASRM,  2004,  at  S261.  242  Id.  243  Hill,  2003.  244  Brock,  2005,  at  274.  245  Id.  

  83  

  If  professional  medical  organizations  drafted  statements  directly  addressing  

PMGR  and  PVSGR,   then   those   statements  would  have   great  weight   in   the  medical  

community.   Such   statements   could   fill   in   the   gaps   between   hospital   policies   and  

"inform   lawmakers   about   what   the   law   should   be." 246  However,   the   leading  

professional   organizations   have   not   clearly   addressed   PMGR   and   PVSGR,   even  

though  they  are  probably  well  aware  of  the  concerns  arising  from  PMGR  and  PVSGR  

and   aware   that   the   procedures   are   becoming   more   common.   This   leads   me   to  

conclude   that   stronger   professional   organization   statements   or   guidelines   are  

unlikely   to   be   drafted   any   time   soon.   So,   until   such   statements   are   released   and  

evaluated,   hospital   PMGR   and   PVSGR   policies   are   the   best   way   to   sufficiently  

address  the  concerns  arising  from  the  procedures.    

   

                                                                                                               246  Id.    

  84  

CONCLUSION  

   

  For   over   thirty   years,   PMGR   and   PVSGR   have   raised   serious   ethical,   legal,  

social,   and   practical   concerns.   These   concerns   only   grow   as   PMGR   and   PVSGR  

become  more  common.  So  far,  legislation  and  professional  guidelines  have  failed  to  

properly   address   these   concerns.   This   has   left   the   medical   community   largely  

without   clear   guidance   as   to   how   to   respond   to   increasing   PMGR   and   PVSGR  

requests.  Many  physicians  have  called  out  for  guidance  on  the  issues  and  hospitals  

have   begun   answering   this   call   by   implementing   their   own   PMGR   and   PVSGR  

policies  to  help  guide  decision-­‐making.    

  In  general,  PMGR  and  PVSGR  procedures   should  not  be  prohibited  because  

doing   so  may   violate   individuals'   basic   right   to   procreate.  However,   this   does   not  

mean  that  every  PMGR  and  PVSGR  request  citing  reproductive  autonomy  should  be  

honored.  Doing  so  may  violate  the  patient's  basic  right  not  procreate.  Therefore,  the  

key   to   determining   whether   PMGR   and   PVSGR   requests   should   be   honored   is  

whether  the  deceased  or  PVS  patient  wanted  the  procedure  and  wanted  to  create  a  

child   born   after   the  patient's   death   or  while   the  patient   is   in  PVS.   In   this   thesis,   I  

have  argued  that  only  the  patient's  written  explicit  consent  sufficiently  protects  his  

or   her   autonomy   because   it   is   the   only   non-­‐speculative   way   to   determine   the  

patient's  wishes  regarding  PMGR  and  PVSGR.    

  In   the   absence  of   the  patient's   explicit  written   consent   to  PMGR  or  PVSGR,  

surrogate  decision  makers  should  not  be  allowed  to  determine  whether  the  patient  

wanted  or  would  have  wanted  PMGR  and  PVSGR.  I  have  argued  that  since  surrogate  

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decision  makers   are   usually   the   recipients   of   the   requested   gametes,   they   are   an  

interested  party  and  may  be   influenced   to  present  evidence   that   serves   their  own  

interests  instead  of  the  interest  of  the  patient.  I  have  argued  that  PMGR  and  PVSGR  

requests  by  non-­‐intimate  partners   (e.g.,   parents)   should  not  be  honored.  Also,   the  

treatment  of  grief  is  not  a  permissible  reason,  by  itself,  to  perform  PMGR  or  PVSGR.  I  

have  argued  that  the  welfare  of  the  future  child  should  be  considered  in  every  PMGR  

and  PVSGR   situation.  This   should  not  necessarily  prevent   a  PMGR  or  PVSGR   from  

occurring,   but   should   encourage   the   medical   team   to   refer   the   deceased   or   PVS  

patient's   intimate   partner   to   their   hospitals   legal   department   so   they   can   be  

informed  of  the  legal  consequences  the  future  child  might  experience  as  a  result  of  

PMGR  and  PVSGR.    

  A   lingering   question   I   set   out   to   answer   in   this   thesis   is   whether   hospital  

policies   can   sufficiently   address   the   legal,   ethical,   social,   and   practical   concerns  

arising   from  PMGR  and  PVSGR.  After   conducting   interviews,   reviewing  PMGR  and  

PVSGR  literature,  and  comparing  numerous  hospital  policies,  I  believe  that  hospital  

policies   can   and   often   do   address   the   ethical,   legal,   social,   and   practical  

considerations   arising   from   PMGR   and   PVSGR,   even   though   these   policies   vary  

considerably   in  how   they  address   these   considerations.  These   considerations  may  

be   addressed   by   alternatives,   such   as   legislation   or   professional   organization  

guidelines,  but  these  alternatives  are  either  underdeveloped  or  severely  inadequate  

to  sufficiently  address  PMGR  and  PVSGR.  

  Finally,   due   to   the   complexity  of   the   issues   arising   from  PMGR  and  PVSGR,  

the  emotions  involved  in  the  process,  and  the  relatively  small  window  of  time  when  

  86  

gametes   can   be   retrieved   (in   PMGR),   I   recommend   that   hospitals   should   adopt  

PMGR  and  PVSGR  policies  before  they  receive  their  first  PMGR  or  PVSGR  request,  or  

as  quickly  as  possible  before  more  are  received.    

 

 

 

 

 

     

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REFERENCES      American  Society  For  Reproductive  Medicine,  The  Ethics  Committee,  Ethical  Considerations  Of  Assisted  Reproductive  Technologies,  67  Fertility  And  Sterility  8S  (1997).    American  Society  For  Reproductive  Medicine,  The  Ethics  Committee,  Posthumous  Reproduction,  82  Fertility  And  Sterility  260  (2004).    Andrews,  Lori  B.,  The  Sperminator,  New  York  Times  Magazine  62  (Mar  28,  1999).    Arkansas  Children's  Hospital  Policy,  Retrieving  Male  or  Female  Gametes  From  Deceased,  Comatose  Persistent  Vegetative  State  or  Brain  Dead  Patients.  Accessed  at:  http://www.pediatricethics.org/index.php?option=com_content&view=article&id=15&Itemid=17    Arthur,  Charles,  Woman  Is  Pregnant  By  Sperm  Of  Dead  Man,  The  Independent  (July  16,  1998)  Available  at  http://findarticles.com/p/articles/mi_qn4158/is_19980716/ai_n14178686.    Astrue  v.  Capato,  132  S.Ct.  2021  (2012).    A.Z.  v.  B.Z.,  431  Mass.  150  (2000).    Bahadur,  G.,  Death  And  Conception,  17  Human  Reproduction  2769  (2002).    Bahadur,  G.,  Ethical  Challenges  In  Reproductive  Medicine:  Posthumous  Reproduction,  1266  International  Congress  Series  295  (2004).      Barton,  Sara  E.  et  al.,  Population-­‐Based  Study  of  Attitudes  Toward  Posthumous  Reproduction,  98  Fertility  and  Sterility  735  (2012).    Batzer,  Frances  et  al.,  Postmortem  Parenthood  And  The  Need  For  A  Protocol  With  Posthumous  Sperm  Procurement,  79  Fertility  And  Sterility  1263  (2003).    Beauchamp,  Tom  and  James  Childress,  Principles  of  Biomedical  Ethics,  (New  York:  Oxford  Press.  2009).    Belker,  Arnold,  Live  Birth  After  Sperm  Retrieval  From  A  Moribund  Man,  76  Fertility  And  Sterility  841  (2001).    Brock,  Lisa  V.  &  Anna  C.  Mastroianni,  Sperm  and  Egg  Retrieval  for  Posthumous  Reproduction:  Practical,  Ethical,  and  Legal  Considerations,  Contemporary  Endocrinology:  Office  Andrology  (Human  Press,  2005).    

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Cannold,  L,  Who  Owns  a  Dead  Man's  Sperm?,  30  J  Med.  Ethics  386  (2003).    Carpenter,  Benjamin,  A  Chip  Off  The  Old  Iceblock:  How  Cryopreservation  Has  Changed  Estate  Law,  Why  Attempts  To  Address  The  Issue  Have  Fallen  Short,  And  How  To  Fix  It,  21  Cornell  J.L.  &  Pub.  Pol'y  #    Clarke,  Gary  N.,    A.R.T.  and  history,  1678-­‐1978,  21  Human  Reproduction  1645  (2006).    Coghlan,  Andy,  Some  Coma  Patients  'Feel  Pain',  New  Scientist  (Oct.  7,  2008).  Available  at:  http://www.newscientist.com/article/dn14891-­‐some-­‐coma-­‐patients-­‐feel-­‐pain.html    Cohen,  I.  Glenn,  The  Right  Not  To  Be  A  Parent?,  81  S.  Cal.  L.  Rev.  1115  (2007).    Cohen,  Philip,  Life  After  Death-­‐New  York  State  Moves  To  Keep  Dead  Men's  Sperm  In  The  Family,  2126  New  Scientist  2323  (1998).    Davis  v.  Davis,  842  S.W.2d  588  (Tenn.  1992).    Dotsal,    J.  et  al.,  Post-­‐mortem  Sperm  Retrieval  In  New  European  Union  Countries:  Case  Report,  20  Human  Reproduction  2359  (2005).    Duke  Hospital  Mission  Statement.  Accessed  at:  <http://www.dukehealth.org/locations/duke_hospital/location_details/duke_university_hospital_mission>    Duke  University  Hospital,  Personal  Communications  (do  not  have  a  policy).    East  Carolina  University's  Vidant  Medical  Center,  Personal  Communications  (unwritten  policy).    Eisenstadt  v.  Baird,  05  U.S.  438  (1972).    Elliott,  Michael  K.,  Tales  Of  Parenthood  From  The  Crypt:  The  Predicament  Of  The  Posthumously  Conceived  Child,  39  Real  Prop.  Prob.  &  Tr.  J.  47  (2004).    Epker,  J.  L.  et  al.,  Ethical  and  Practical  Considerations  Concerning  Perimortem  Sperm  Procurement  In  a  Severe  Neurologically  Damaged  Patient  and  the  Apparent  Discrepancy  In  Validation  of  Proxy  Consent  In  Various  Postmortem  Procedures,  38  Intensive  Care  Med  1069  (2012).    Fader,  Sonia,  Sperm  Banking  History:  An  Excerpt,  Sperm  Banking:  A  Reproductive  Resource.  Available  at:  http://www.cryobank.com/Learning-­‐Center/Sperm-­‐Banking-­‐101/Sperm-­‐Banking-­‐History/    

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Finnerty,  James  J.  et  al.,  Gamete  Retrieval  In  Terminal  Conditions,  185  American  Journal  of  Obstetrics  and  Gynecology  300  (2001).    Finnerty,  James  J.  et  al,  Gamete  Retrieval  In  Terminal  Conditions:  Is  It  Practical?  What  Are  the  Consequences?  2  Current  Women's  Health  Reports  175  (2002).    Fisher,  Ian,  Bill  Would  Govern  Use  of  Dead  Men's  Sperm,  NY  Times  B5  (Mar  7,  1998).    Gottenger,  E.E.  &  H.M.  Nagler,  The  Quagmire  Of  Postmortem  Sperm  Acquisition,  20  J  Andrology  458  (1999).    Greer,  David  M.,  et  al.,  Case  21-­‐2010:  A  Request  For  Retrieval  Of  Oocytes  From  A  36-­‐Year-­‐Old  Woman  With  Anoxic  Brain  Injury,  363  New.  Eng.  J.  Med.  276  (2010).    Griswold  v.  Connecticut,  381  U.S.  479  (1965).    Hecht  v.  Superior  Court,  20  Cal.  Rptr.  2d  275  (Cal.  Ct.  App.  1993).    Hill,  Joal,  Posthumous  Sperm  Retrieval,  361  The  Lancet  1834  (2003).    In  re  Estate  of  Kolacy,  753  A.2d  1257,  1263  (N.J.  Super.  Ct.  Ch.  Div.  2000).    James,  Susan  Donaldson,  Sperm  Retrieval:  Mother  Creates  Life  After  Death,  ABC  News  (Feb.  2010).    Kahan,  Steven,  Postmortem  Sperm  Procurement:  A  Legal  Perspective,  161  Journal  Of  Urology  1840  (1999).    Kass  v.  Kass,  No.  19658/93,  1995  WL  110368  (N.Y.  Sup.  Ct.  Jan.  18,  1995).    Katz,  Katheryn  D.,  Parenthood  From  The  Grave:  Protocols  For  Retrieving  And  Utilizing  Gametes  From  The  Dead  Or  Dying,  University  Of  Chicago  Legal  Forum  289  (2006).    Kerr,  Susan  M.  et  al.,  Postmortem  Sperm  Procurement,  157  Journal  Of  Urology  2154  (1997).    Knaplund,  Kristine  S.,  Children  Of  Assisted  Reproduction,  45  Univ.  Of  Michigan  Journal  Of  Law  Reform  899  (2012).    Knaplund,  Kristine  S.,  Postmortem  Conception  And  A  Father's  Last  Will,  46  Ariz.  L.  Rev.  91  (2004).    Lahey  Clinic  Policy,  5166  Sperm  Retrieval  From  Dead  or  Irreversibly  Comatose  Patients,  Clinical  and  Administrative  Policy  and  Procedure  Manual  93-­‐a,  Available  at:  

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http://www.lahey.org/Education_and_Research/Medical_Ethics/Medical_Ethics_Policies.aspx.  Accessed  November  13,  2012.        Louinn,  Lota,  Baby  Born  From  Dead  Man's  Sperm.  The  Philadelphia  Inquirer  (1999).    The  Multi-­‐Society  Task  Force  On  PVS,  Medical  Aspects  of  the  Persistent  Vegetative  State,  330  N  Engl  J  Med  1499  (1994).    Murphy,  Timothy  &  Gladys  White,  Dead  Sperm  Donors  Or  World  Hunger:  Are  Bioethicists  Studying  The  Right  Stuff?  35  Hastings  Center  Report  2  (2005).    Nakhuda,  Gary  S.  et  al.,  Posthumous  Assisted  Reproduction:  A  Survey  Of  Attitudes  Of  Couples  Seeking  Fertility  Treatment  And  The  Degree  Of  Agreement  Between  Intimate  Partners,  96  Fertility  and  Sterility  1463  (2011).    N.C.  GEN.  STAT.  §  29-­‐9    California  Baby  Born  Using  Sperm  From  Dead  Father,  Charleston  Gazette  (West  Virginia)  P2A  (March  27,  1999).    New  York  Hospital  Guidelines  for  Consideration  of  Requests  for  Post-­‐mortem  Sperm  Retrieval.  Available  at:  https://www.cornellurology.com/resources/guidelines/  Accessed  November  13,  2012.      North  Carolina  Power  of  Attorney  Form.  Accessed  at  http://www.secretary.state.nc.us/ahcdr/Forms.aspx    Northwestern  Memorial  Hospital,  Personal  Communications  (currently  drafting  a  policy).    OHSU  Health  Care  System  Policy,  Post-­‐Mortem  Sperm  Retrieval,  HC-­‐CLN-­‐EXP-­‐P005  (Jan.  13,  2012).      Ohl,  Dana  A.  et  al.,  Procreation  After  Death  Or  Mental  Incompetence:  Medical  Advance  Or  Technology  Gone  Awry?,  66  Fertility  And  Sterility  889  (1996).    Orr,  R.  D.  &  M.  Siegler,  Is  Posthumous  Semen  Retrieval  Ethically  Permissible?,  28  J  Med  Ethics  299  (2002).    Pennings,  G.  et  al.,  ESHRE  Task  Force  On  Ethics  And  Law  11:  Posthumous  Assisted  Reproduction,  21  Human  Reproduction  3050  (2006).    Pierce  v.  Proprietors  of  Swan  Point  Cemetery,  10  R.I.  227  (1872).    Radford,  Mary  F.,  Post-­‐Mortem  Sperm  Retrieval  And  The  Social  Security  Administration:  How  Modern  Reproductive  Technology  Makes  Strange  Bedfellows,  

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Georgia  State  University  College  of  Law,  Legal  Studies  Research  Paper.  Available  at:  http://ssrn.com/abstract=1376402    Robertson,  John  A.,  Posthumous  Reproduction,  69  Ind  L  J  1027  (1994).    Rothman,  Cappy  Miles,  Live  Sperm,  Dead  Bodies,  20  J  Andrology  456  (1999).    Schiff,  Ann  Reichman,  Arising  From  The  Dead:  Challenges  Of  Posthumous  Procreation,  75  NC  L  Rev  901  (1997).    Shefi,  Shai  et  al.,  Posthumous  Sperm  Retrieval:  Analysis  Of  Time  Interval  To  Harvest  Sperm,  21  Human  Reproduction  2890  (2006).    Soules,  Michael  R.,  Commentary:  Posthumous  Harvesting  of  Gametes  A  Physician's  Perspective,  27  J  L  Med  &  Ethics  362,  363  (1999).    Spielman,  Bethany,  Post  Mortem  Gamete  Retrieval  After  Christy,  5  ABA  Health  Esource  (October  2008).      Spielman,  Bethany,  Pushing  The  Dead  Into  The  Next  Reproductive  Frontier:  Post  Mortem  Gamete  Retrieval  Under  The  Uniform  Anatomical  Gift  Act,  37  Journal  Of  Law,  Medicine  &  Ethics  331  (2009).    Strong,  Carson,  Consent  To  Sperm  Retrieval  And  Insemination  After  Death  Or  Persistent  Vegetative  State,  14  J.L.  &  Health  243  (1999).    Strong,  Carson  et  al,  Ethics  Of  Sperm  Retrieval  After  Death  Or  Persistent  Vegetative  State,  15  Human  Reproduction  739  (2000).    Strong,  Carson,  Gamete  Retrieval  After  Death  Or  Irreversible  Unconsciousness:  What  Counts  As  Informed  Consent?  15  Cambridge  Quarterly  Of  Healthcare  Ethics  161  (2006).    Sutton,  Stacey,  The  Real  Sexual  Revolution:  Posthumously  Conceived  Children,  73  St.  John's  Law  Rev.  857  (1999).    Tash,  Jennifer  A.  et  al.,  Postmortem  Sperm  Retrieval:  The  Effect  Of  Instituting  Guidelines,  170  J  Urology  1922  (2003).    University  of  North  Carolina  Health  Care  Policy,  Gamete  Collection  For  Permanently  Unconscious  or  Deceased  Patients,  Admin  0210  (Sept.  2010).    University  of  North  Carolina  Hospital  Mission  Statement.  Accessed  at:  <http://www.unchealthcare.org/site/aboutus/mission.htm>    

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University  of  Virginia  Health  System  Policy,  Policy  For  Retrieving  Male  or  Female  Gametes  From  Dead  Subjects,  Comatose  Persons,  Persons  in  Persistent  Vegetative  State  or  Brain  Dead  Subjects.  See  James  J.  Finnerty  et  al.,  Gamete  Retrieval  in  Terminal  Conditions:  Is  it  Practical?  What  Are  the  Consequences?,  2  Current  Women's  Health  Reports  175,  177  (2002).    University  of  Washington  Policy.  See  M.  R.  Soules,  Posthumous  Harvesting  of  Gametes  -­‐  A  Physicians  Perspective,  27  Journal  of  Law,  Medicine  &  Ethics  362,  364  (1999).    Wake  Forest  Baptist  Medical  Center  Mission  Statement.  Accessed  at:  <http://www.wakehealth.edu/Mission-­‐Statement.htm>    Wake  Forest  Baptist  Medical  Center  Policy,  Gamete  Recovery  From  Newly  Dead  or  Irreversibly  Unconscious  Patients  (4th  draft,  June  9,  2009).    White,  Gladys  B.,  Commentary:  Legal  and  Ethical  Aspects  of  Sperm  Retrieval,  27  J  L  Med  &  Ethics  359  (1999).    Williams,  Devon  D.,  Over  My  Dead  Body:  The  Legal  Nightmare  And  Medical  Phenomenon  Of  Posthumous  Conception  Through  Postmortem  Sperm  Retrieval,  34  Campbell  L  Rev  181  (2011).    Woodward  v.  Commissioner  of  Social  Security,  760  N.E.  2d  257  (Mass.  2002).  

   

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APPENDIX  I:  EXCLUSIONARY  CRITERIA  TABLE        

Policy   Policy  Type   Consent   Recipient/  

Requestor  Retrieval  Time   Waiting  Period   Economic  

Arkansas  Children's  Hospital  

PMGR  &  PVSGR  

Written  Explicit  Consent  (signed  and  witnessed)  

Patient  Named  Custodian  (in  charge  of  storing  and  distributing  gametes  according  to  patient's  wishes)  

-­‐-­‐   -­‐-­‐   Responsibility  of  the  custodian.  

Duke   No  Policy   -­‐-­‐   -­‐-­‐   -­‐-­‐   -­‐-­‐   -­‐-­‐  The  Lahey  Clinic  

PMGR  &  PVSGR  

1.  Written  Explicit  Consent  (signed  and  notarized)  or  If  HC  provider  can  provide  documentation  in  the  patient's  written  records  2.  Authorization  by  Patient's  next  of  kin  (deceased)  or  Surrogate  Decision  Maker  (PVS).  

Patient  named  recipient  (anyone)  

-­‐-­‐   -­‐-­‐   Responsibility  of  the  individual  authorizing  the  gamete  retrieval  

New  York  Hospital  Guidelines  

PMGR   Explicit  prior  or  reasonably  inferred  consent  determined  by  actions  and  discussions  prior  to  death  

Wife  only.   Within  24  hrs.  of  death  

Required  1-­‐year  (wife  must  undergo  medical  and  psychological  consultations  

-­‐-­‐  

Northwestern  Memorial  Hospital  

PMGR  (Draft)  

Written  Explicit  Consent.  In  extremely  rare  circumstances  compelling  evidence  of  patient's  wishes  are  considered  without  prior  written  explicit  consent.  

-­‐-­‐   -­‐-­‐   -­‐-­‐   -­‐-­‐  

OHSU  Health  Care  System  

PMGR   Written  Explicit  Consent  or  verbal  consent    If  Directed  Donation:  Written  Explicit  Consent  

Only  surviving  partner,  unless  directed  donation.  If  directed  donation  then  anyone  the  patient  named  in  written  explicit  consent.  

-­‐-­‐   Required  3-­‐month  

Responsibility  of  the  surviving  partner  or  directed  donor  recipient.  

University  of  North  Carolina  Hospital  

PMGR  &  PVSGR  

Written  Explicit  Consent  

Only  patient  identified  intimate  partner  

Within  24-­‐hours  of  death  

Recommended  1-­‐year  

Responsibility  of  the  intimate  partner.  

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Policy   Policy  Type   Consent   Recipient/  

Requestor  Retrieval  Time   Waiting  Period   Economic  

University  of  Virginia  Health  System  

PMGR  &  PVSGR  

Written  Explicit  Consent  (1.  indicates  consent  to  use  retrieved  gametes  for  procreation;  2.  names  the  person  intended  to  be  both  the  recipient  and  user  of  gametes;  3.  declares  willingness,  or  unwillingness,  to  be  recognized  as  the  parent;  4.  signed  and  witnessed.)  

Named  requestor  who  is  not  the  parent,  grandparent,  child  or  first  cousin  of  the  patient;  and,  the  requestor  is  also  to  be  the  partner  in  any  attempt  to  procreate  with  the  retrieved  gametes.  

-­‐-­‐   2  sessions  with  a  psychologist  or  psychiatrist,  who  must  provide  a  statement  that  the  named  recipient  is  prepared  to  undergo  procedures.  

Responsibility  of  the  named  recipient.  

The  University  of  Washington  

PMGR   Written  Explicit  Consent  

-­‐-­‐   -­‐-­‐   -­‐-­‐   -­‐-­‐  

Vidant  Medical  Center  (East  Carolina  University's  Brody  School  of  Medicine)  

PMGR  (unwritten)  

Written  Explicit  Consent  

Wife,  girlfriend  or  mother.  

-­‐-­‐   -­‐-­‐   -­‐-­‐  

Wake  Forest  Baptist  Medical  Center  

PMGR  &  PVSGR  (Draft)  

Consent  provided  by  the  patient's  legally  determined  surrogate  decision  maker  (guided  by  the  patient's  previously  expressed  wishes;  If  none  then  can  use  the  substituted  judgment  standard.)  

Patient's  intimate  partner.  

-­‐-­‐   None,  but  should  offer  referral  for  support  and  bereavement  counseling.  

Responsibility  of  the  intimate  partner.  

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CURRICULUM  VITAE        PERSONAL  INFORMATION    Name:         Tyrel  James  Hooker    Address:       500  Clarion  Bridge  Way  Apt.  523           Morrisville,  NC  27560    Telephone:       (512)  670-­‐6488    Email:         tyrelhooker@gmail.com    Date  and  Place  of  Birth:   October  10,  1985           Odessa,  Texas        EDUCATION    Graduate:       Masters  of  Arts  in  Bioethics             Wake  Forest  University             Winston-­‐Salem,  North  Carolina             January  2011  –  present             Anticipated  Date  of  Graduation  –  December  2012    Law  School:       Juris  Doctorate  of  Law           Wake  Forest  University           Winston-­‐Salem,  North  Carolina           August  2009  -­‐  present           Anticipated  Date  of  Graduation  -­‐  December  2012    Undergraduate:     B.A.  of  Liberal  Arts,  History           The  University  of  Texas  -­‐  Austin           Austin,  Texas           February  2006  -­‐  December  2008                  

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ACADEMIC  HONORS  AND  AWARDS    Law  Alumni  Counsel  Scholarship:  Fall  2009  -­‐  May  2012    CALI  Award:  Spring  2012    Business  Foundations  Certificate  with  "Highest  Honors"    University  of  Texas  Honors:    Fall  2007,  Fall  2008        PUBLICATIONS    Aragon,  Stephen  et.  al.,  Patient-­‐Centeredness:  A  Best  Practice  for  HBCU  Health  Professional  Education  Programs?,  forthcoming  in  The  Journal  of  Best  Practice  in  Health  Professions  Diversity:  Research,  Education  &  Policy.