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Artificial Insemination
LEADING
ARTICLES
THE LANCET LONDON
30
JULY 1960
Artificial Insemination IN this country the number of children conceived as a result of artificial insemination with a donor’s semen (A.I.D.) is probably just over a hundred a year. Although the practice is increasing-the number of such conceptions has apparently doubled in the past decade-and may further increase as a result of recent publicity, the
number of children born in this way is not likely to reach significant proportions in the foreseeable future. Even if A.I.D. were to increase twentyfold, a marriage between children of the same donor would be unlikely to occur more than once in fifty to a hundred years. In the great majority of cases, A.I.D. is used because of sterility or gross infertility in the husband. Very occasionally it is undertaken for other reasons-for instance, where the husband has severe hereditary disease or where there is rhesus incompatibility. According to evidence given to the departmental committee whose report was published last week/ A.I.D. is undertaken in this country only if both husband and wife agree, and even then only after careful consideration. " The practitioner tries to establish not only that the child is likely to have a secure material background, but also that the marriage is likely to remain stable and harmonious; that husband and wife are entirely suited in personality and aware of the temperament to have a donor child, and " are undertaking. Practitioners responsibilities they occasionally receive inquiries from single women but never proceed. Notwithstanding some suggestions to the contrary, the departmental committee’s report indicates that the practitioners and the couples concerned behave with a due sense of responsibility. What, then, should be society’s attitude towards donor
insemination-encouragement, tolerance, or disapproval ? On this issue the committee was divided. None of its members favours A.i.D. for single women, widows, or wives separated from their husbands, or for married women without the husband’s consent; and the majority believe that, even with the husband’s consent, A.I.D. is an undesirable practice and should be discouraged as " an offence against society " and as " most unwise and a grave injustice ... to the intended child". They do not wish to make it a criminal offence, which they would regard as dangerous. They would place it in the category of conduct which, although regarded by the community as immoral, should not be classed as criminal and therefore punishable by the State. The minority, though not in favour of encouraging A.i.D., maintain that it may properly be employed in small numbers of cases provided that the marriage is stable and both applicants and donors are carefully and expertly selected. In such cases A.I.D. 1.
Report of the Departmental Committee on Human Artificial Insemination. Cmnd 1105. H.M. Stationery Office. 5s. 6d.
’
247
should not be classed as discreditable, and the children should be regarded by the law as legitimate. Both the majority and the minority propose only minor legal changes, and on most of these the committee was unanimous:for instance, that the acceptance of donor insemination without the husband’s consent should be a ground for divorce. The absence of proposals for controversial legislation should encourage reasoned discussion of this difficult problem. Are the majority justified in so strongly condemning the practice of donor insemination ? They appear to have the support of many doctors as well as of religious bodies and other organised opinion. None the less, some of the objections seem to be concerned with risks to be considered by a couple contemplating A.I.D. rather than with matters of principle. No doubt, the reception by the wife of the seed of another man may give rise to emotional difficulties, and either husband or wife may later regret the birth of an artificially conceived child. But this is no more a question of principle than is the possibility that a couple may subsequently regret their decision to adopt a child. And, while the committee properly draws attention to the needs and rights of the intended child, too much can be made of the risks. The majority are in effect saying that it were better for the child not to have been born than for it to run the risk of emotional disturbance on learning of its A.I.D. origin. The majority do, however, raise a question of principle in considering whether A.I.D. is compatible with the sanctity of marriage. They see clearly enough-which has not been apparent to some commentators-that donor insemination and adultery are poles apart; but that, as in adultery, the wife receives the seed of a man other than her husband they evidently regard as a fatal objection. " To many this is a decisive argument against A.I.D. Even though its effects on the marriage were in all cases wholly good, it would go against what has hitherto been regarded as the essential nature of marriage." This is to enter the realm partly of theology and partly of the ingrained attitudes of society at large. The technique of insemination is still so new that the attitudes of both theology and society may change as the issues are further debated. For, as the majority report recognises, the history of the institution of marriage shows that the main threat to the physical side of the union has always been adultery and that the undertaking, given at marriage, to " forsake all other " is primarily an undertaking to refrain from adultery. The practice of A.I.D. must of course place a heavy responsibility on the doctor. He can hardly escape advising the couple as to the desirability of their seeking a child by this means; and, if artificial insemination is undertaken, he will have to choose the donor. The majority report suggests that in many respects the practice of A.I.D. is beyond the proper jurisdiction of a doctor, and it names this as another reason for disapproving of donor insemination. On the other hand, it can be argued that the doctor may decide whether he is prepared to accept this responsibility. Whether or not one agrees with its conclusions, this is
248
valuable report which should stimulate discussion. It would be unfortunate if the subject were quietly put aside because it involves only a tiny fraction of births. In the United States A.I.D. is apparently more widely practised,and in this country the demand is quite likely to increase. A clear medical and public opinion is therefore desirable.
a
out that our
knowledge of many of the factors concerned
in this process rests on measurements of the tensile strength of sutured wounds. From three or four days after the wound is made the tensile strength increases rapidly until about the fourteenth day and then very gradually for up to a year. DUNPHY declares that the deleterious effect on the healing process of vitamin-C deficiency and protein starvation depends entirely on Healing of Wounds their timing: if there is no deficiency at the time of MucH time, thought, and investigation have been wounding, repair will proceed normally even if the devoted to the healing of wounds. Professor DUNPHY,3 deficiency develops later. Similarly, cortisone in large in a Moynihan lecture, has sifted out material of value doses depresses the formation of collagen only if healing to the surgeon. He emphasises the importance of has not started. Immediately after total-body irradiation, considering the various components of repair-epi- healing proceeds normally, but it may be impaired later thelialisation, contraction, connective-tissue growth, and because of bleeding from hypoprothrombinaemia. repair of specialised tissues-as separate though interApart from these " outside " factors, the initial three related biological processes of which one may be retarded by physical or chemical agents while the others to four days’ delay in development of tensile strength is of great interest to surgeons. Originally thought to be proceed normally. In incised wounds the epithelium does not merely a lag phase related to demolition and reorganisation in the wound,lo this interval is regarded by DUNPHY as bridge the gap but grows down to the deeper structures, where it proliferates irregularly and, only after collagen preparative, since fibroblastic activity follows very fibres appear, regresses to be arranged in a normal quicklv after the iniurv. Many topical agents have been in efforts to hasten this or later stages, but pattern.45 DUNPHY suggests that this interplay between applied the epithelium and connective tissue simulates the quantitative studies indicate that they merely restore initial and regressive phases in neoplasia. But there are impaired healing to normal. This has been shown in another way by WALLACE, 11 who advocates biological at least two further analogues: in chronic ulcers of the skin the epithelium at the edges shows much irregular covers (plasma pellicle, eschar, or skin graft) and a return to Lister’s principle of complete desiccation of wound proliferation and interplay with the deeper tissues and sometimes becomes malignant (Marjolin’s ulcer); and discharge and an outer protective antiseptic bandage. in chronic peptic ulcers the epithelium at the edges Beyond doubt a resutured wound heals more rapidly a fresh primary wound,12 chiefly owing to the undergoes very irregular hyperplasia, and sometimes than absence of the so-called lag phase: this phenomenon considerable extension into the tissues at the base, and can be used for up to a month, though it is making the development of malignancy very difficult to persists most prominent in the first fortnight. With the aim of determine. DUNPHY points out that contraction (which is to be shortening the preparative phase DUNPHY has adminisbacterial pyrogens, which he finds lead to more distinguished from contracture) is greatest on the back tered formation of collagen. Administration of histamine of the neck, the back, the abdomen, and buttocks, and rapid before wounding and during healing was shown by least on the extremities and the front of the chest and neck, and in all burn wounds (where early grafting is BOYD and SMITH 13 to be associated with more rapid and firmer wound healing, judged both histologically and by required). The exact force causing contraction is not measurement while similar adminisknown; but some part of it resides in a narrow edge of tration of of tensile strength; a which lowers substance compound 48/80, tissue round the wound periphery6 and there is also a centripetal force from without this the histamine content of the skin, retarded healing. apparently 7 area. WATTS8 has shown that wound contraction is Professor KAHLSON 14 believes that the effect of histatissue is due not simply to the mine on independent of epithelial regeneration and of growth of histamine regenerating content but to the histamine-forming capacity granulation tissue and is most effective at right-angles (H.F.C.) of the tissue concerned. He and his colleagues to Langer’s lines9 of skin tension: the most rapid healing is obtained by planning the wound to make best use of show on p. 230 of this issue that skin and granulation these tension lines; but, unless the edges of the wound tissue have a relatively low content of histamine, yet have a very high H.F.c.: the histamine is not stored are brought together by sutures, healing will probably locally but is either used up or carried elsewhere. In never be satisfactory. The healing of a wound or gap in the tissues is female rats to which radioactive histidine was adminisconditioned by the rate of growth and strength of the tered, they measured the formation of endogenous connective tissue which fills the gap. DUNPHY points: histamine (as opposed to the use of dietary histamine). The H.F.c. of the skin was raised and the histamine 2. Williams, Glanville. The Sanctity of Life and the Criminal Law; p. 111. content lowered by compound 48/80 or polymyxin B London, 1958. -
,
,
-
’
3. 4. 5. 6. 7. 8. 9.
Dunphy, J. E. Ann. R. Coll. Surg. Engl. 1960, 26, 69. Hartwell, S. W. The Mechanisms of Healing in Human Wounds. Springfield, Ill., 1955. Gillman, T., Penn, J., Bronks, D., Roux, M. Brit. J. Surg. 1955, 43, 141. Lancet, 1958, ii, 1165. Billingham, R. E., Medawar, P. B. J. Anat., Lond. 1955, 89, 114. Watts, G. T. Brit. J. Surg. 1960, 47, 555. Kraissl, C. J. J. plast. reconstr. Surg. 1951, 8, 1.
10. 11. 12. 13. 14.
Howes, E. L., Scoy, J. W., Harvey, S. C. J. Amer. med. Ass. 1929, 92, 42. Howes, E. L., Harvey, S. C., Hewitt, C. Arch. Surg., Chicago, 1939, 38, 934. Wallace, A. B. Scot. med. J. 1960, 5, 279. Savlov, E. D., Dunphy, J. E. Surgery, 1954, 36, 362. Boyd, J. F., Smith, A. N. J. Path. Bact. 1959, 78, 379. Kahlson, G. Lancet, 1960, i, 67.
ARTICLES
THE LANCET LONDON
30
JULY 1960
Artificial Insemination IN this country the number of children conceived as a result of artificial insemination with a donor’s semen (A.I.D.) is probably just over a hundred a year. Although the practice is increasing-the number of such conceptions has apparently doubled in the past decade-and may further increase as a result of recent publicity, the
number of children born in this way is not likely to reach significant proportions in the foreseeable future. Even if A.I.D. were to increase twentyfold, a marriage between children of the same donor would be unlikely to occur more than once in fifty to a hundred years. In the great majority of cases, A.I.D. is used because of sterility or gross infertility in the husband. Very occasionally it is undertaken for other reasons-for instance, where the husband has severe hereditary disease or where there is rhesus incompatibility. According to evidence given to the departmental committee whose report was published last week/ A.I.D. is undertaken in this country only if both husband and wife agree, and even then only after careful consideration. " The practitioner tries to establish not only that the child is likely to have a secure material background, but also that the marriage is likely to remain stable and harmonious; that husband and wife are entirely suited in personality and aware of the temperament to have a donor child, and " are undertaking. Practitioners responsibilities they occasionally receive inquiries from single women but never proceed. Notwithstanding some suggestions to the contrary, the departmental committee’s report indicates that the practitioners and the couples concerned behave with a due sense of responsibility. What, then, should be society’s attitude towards donor
insemination-encouragement, tolerance, or disapproval ? On this issue the committee was divided. None of its members favours A.i.D. for single women, widows, or wives separated from their husbands, or for married women without the husband’s consent; and the majority believe that, even with the husband’s consent, A.I.D. is an undesirable practice and should be discouraged as " an offence against society " and as " most unwise and a grave injustice ... to the intended child". They do not wish to make it a criminal offence, which they would regard as dangerous. They would place it in the category of conduct which, although regarded by the community as immoral, should not be classed as criminal and therefore punishable by the State. The minority, though not in favour of encouraging A.i.D., maintain that it may properly be employed in small numbers of cases provided that the marriage is stable and both applicants and donors are carefully and expertly selected. In such cases A.I.D. 1.
Report of the Departmental Committee on Human Artificial Insemination. Cmnd 1105. H.M. Stationery Office. 5s. 6d.
’
247
should not be classed as discreditable, and the children should be regarded by the law as legitimate. Both the majority and the minority propose only minor legal changes, and on most of these the committee was unanimous:for instance, that the acceptance of donor insemination without the husband’s consent should be a ground for divorce. The absence of proposals for controversial legislation should encourage reasoned discussion of this difficult problem. Are the majority justified in so strongly condemning the practice of donor insemination ? They appear to have the support of many doctors as well as of religious bodies and other organised opinion. None the less, some of the objections seem to be concerned with risks to be considered by a couple contemplating A.I.D. rather than with matters of principle. No doubt, the reception by the wife of the seed of another man may give rise to emotional difficulties, and either husband or wife may later regret the birth of an artificially conceived child. But this is no more a question of principle than is the possibility that a couple may subsequently regret their decision to adopt a child. And, while the committee properly draws attention to the needs and rights of the intended child, too much can be made of the risks. The majority are in effect saying that it were better for the child not to have been born than for it to run the risk of emotional disturbance on learning of its A.I.D. origin. The majority do, however, raise a question of principle in considering whether A.I.D. is compatible with the sanctity of marriage. They see clearly enough-which has not been apparent to some commentators-that donor insemination and adultery are poles apart; but that, as in adultery, the wife receives the seed of a man other than her husband they evidently regard as a fatal objection. " To many this is a decisive argument against A.I.D. Even though its effects on the marriage were in all cases wholly good, it would go against what has hitherto been regarded as the essential nature of marriage." This is to enter the realm partly of theology and partly of the ingrained attitudes of society at large. The technique of insemination is still so new that the attitudes of both theology and society may change as the issues are further debated. For, as the majority report recognises, the history of the institution of marriage shows that the main threat to the physical side of the union has always been adultery and that the undertaking, given at marriage, to " forsake all other " is primarily an undertaking to refrain from adultery. The practice of A.I.D. must of course place a heavy responsibility on the doctor. He can hardly escape advising the couple as to the desirability of their seeking a child by this means; and, if artificial insemination is undertaken, he will have to choose the donor. The majority report suggests that in many respects the practice of A.I.D. is beyond the proper jurisdiction of a doctor, and it names this as another reason for disapproving of donor insemination. On the other hand, it can be argued that the doctor may decide whether he is prepared to accept this responsibility. Whether or not one agrees with its conclusions, this is
248
valuable report which should stimulate discussion. It would be unfortunate if the subject were quietly put aside because it involves only a tiny fraction of births. In the United States A.I.D. is apparently more widely practised,and in this country the demand is quite likely to increase. A clear medical and public opinion is therefore desirable.
a
out that our
knowledge of many of the factors concerned
in this process rests on measurements of the tensile strength of sutured wounds. From three or four days after the wound is made the tensile strength increases rapidly until about the fourteenth day and then very gradually for up to a year. DUNPHY declares that the deleterious effect on the healing process of vitamin-C deficiency and protein starvation depends entirely on Healing of Wounds their timing: if there is no deficiency at the time of MucH time, thought, and investigation have been wounding, repair will proceed normally even if the devoted to the healing of wounds. Professor DUNPHY,3 deficiency develops later. Similarly, cortisone in large in a Moynihan lecture, has sifted out material of value doses depresses the formation of collagen only if healing to the surgeon. He emphasises the importance of has not started. Immediately after total-body irradiation, considering the various components of repair-epi- healing proceeds normally, but it may be impaired later thelialisation, contraction, connective-tissue growth, and because of bleeding from hypoprothrombinaemia. repair of specialised tissues-as separate though interApart from these " outside " factors, the initial three related biological processes of which one may be retarded by physical or chemical agents while the others to four days’ delay in development of tensile strength is of great interest to surgeons. Originally thought to be proceed normally. In incised wounds the epithelium does not merely a lag phase related to demolition and reorganisation in the wound,lo this interval is regarded by DUNPHY as bridge the gap but grows down to the deeper structures, where it proliferates irregularly and, only after collagen preparative, since fibroblastic activity follows very fibres appear, regresses to be arranged in a normal quicklv after the iniurv. Many topical agents have been in efforts to hasten this or later stages, but pattern.45 DUNPHY suggests that this interplay between applied the epithelium and connective tissue simulates the quantitative studies indicate that they merely restore initial and regressive phases in neoplasia. But there are impaired healing to normal. This has been shown in another way by WALLACE, 11 who advocates biological at least two further analogues: in chronic ulcers of the skin the epithelium at the edges shows much irregular covers (plasma pellicle, eschar, or skin graft) and a return to Lister’s principle of complete desiccation of wound proliferation and interplay with the deeper tissues and sometimes becomes malignant (Marjolin’s ulcer); and discharge and an outer protective antiseptic bandage. in chronic peptic ulcers the epithelium at the edges Beyond doubt a resutured wound heals more rapidly a fresh primary wound,12 chiefly owing to the undergoes very irregular hyperplasia, and sometimes than absence of the so-called lag phase: this phenomenon considerable extension into the tissues at the base, and can be used for up to a month, though it is making the development of malignancy very difficult to persists most prominent in the first fortnight. With the aim of determine. DUNPHY points out that contraction (which is to be shortening the preparative phase DUNPHY has adminisbacterial pyrogens, which he finds lead to more distinguished from contracture) is greatest on the back tered formation of collagen. Administration of histamine of the neck, the back, the abdomen, and buttocks, and rapid before wounding and during healing was shown by least on the extremities and the front of the chest and neck, and in all burn wounds (where early grafting is BOYD and SMITH 13 to be associated with more rapid and firmer wound healing, judged both histologically and by required). The exact force causing contraction is not measurement while similar adminisknown; but some part of it resides in a narrow edge of tration of of tensile strength; a which lowers substance compound 48/80, tissue round the wound periphery6 and there is also a centripetal force from without this the histamine content of the skin, retarded healing. apparently 7 area. WATTS8 has shown that wound contraction is Professor KAHLSON 14 believes that the effect of histatissue is due not simply to the mine on independent of epithelial regeneration and of growth of histamine regenerating content but to the histamine-forming capacity granulation tissue and is most effective at right-angles (H.F.C.) of the tissue concerned. He and his colleagues to Langer’s lines9 of skin tension: the most rapid healing is obtained by planning the wound to make best use of show on p. 230 of this issue that skin and granulation these tension lines; but, unless the edges of the wound tissue have a relatively low content of histamine, yet have a very high H.F.c.: the histamine is not stored are brought together by sutures, healing will probably locally but is either used up or carried elsewhere. In never be satisfactory. The healing of a wound or gap in the tissues is female rats to which radioactive histidine was adminisconditioned by the rate of growth and strength of the tered, they measured the formation of endogenous connective tissue which fills the gap. DUNPHY points: histamine (as opposed to the use of dietary histamine). The H.F.c. of the skin was raised and the histamine 2. Williams, Glanville. The Sanctity of Life and the Criminal Law; p. 111. content lowered by compound 48/80 or polymyxin B London, 1958. -
,
,
-
’
3. 4. 5. 6. 7. 8. 9.
Dunphy, J. E. Ann. R. Coll. Surg. Engl. 1960, 26, 69. Hartwell, S. W. The Mechanisms of Healing in Human Wounds. Springfield, Ill., 1955. Gillman, T., Penn, J., Bronks, D., Roux, M. Brit. J. Surg. 1955, 43, 141. Lancet, 1958, ii, 1165. Billingham, R. E., Medawar, P. B. J. Anat., Lond. 1955, 89, 114. Watts, G. T. Brit. J. Surg. 1960, 47, 555. Kraissl, C. J. J. plast. reconstr. Surg. 1951, 8, 1.
10. 11. 12. 13. 14.
Howes, E. L., Scoy, J. W., Harvey, S. C. J. Amer. med. Ass. 1929, 92, 42. Howes, E. L., Harvey, S. C., Hewitt, C. Arch. Surg., Chicago, 1939, 38, 934. Wallace, A. B. Scot. med. J. 1960, 5, 279. Savlov, E. D., Dunphy, J. E. Surgery, 1954, 36, 362. Boyd, J. F., Smith, A. N. J. Path. Bact. 1959, 78, 379. Kahlson, G. Lancet, 1960, i, 67.