These observations provide material for an empirically grounded bioethics of the IVF–stem cell interface (Franklin 2006). In the rest of this paper, we consider a single aspect in detail: the potential “problem” of gratitude influencing informed consent.
Empirically, the main reasons given by our participants for donation were: (1) to avoid the waste of a precious resource, (2) to give something back to research, and (3) to compensate for a perceived moral wrong. In none of the three countries did our participants indicate that their decision arose out of any sense of gratitude to the physician who had given them IVF treatment. This is an important observation, because the possible impact of gratitude on informed consent in embryo donation has previously been raised by bioethical commentators. It has been suggested that if there is any institutional or procedural link between IVF treatment and hESC research, the potential donors’ gratitude toward the clinicians who have helped them to conceive may steer them toward opting for donation (Haimes and Luce 2006; Parry 2006; McLeod and Baylis 2007; also discussed in Roberts and Throsby 2008). The bioethical concern is that parents who receive the “gift of a baby” will feel a sense of gratitude; feeling grateful might then cause parents to feel that they should respond with a gift in return; and if a request for donation of surplus embryos is made in that context, potential donors might inadvertently be encouraged to see donation as an appropriate form of return gift. In this way the moral emotion of gratitude could compromise the potential donor’s freedom to weigh the pros and cons of the request, which in turn means compromising the capacity to give fully voluntary consent. Even where the clinicians and researchers themselves are scrupulous about not using persuasion, gratitude might be persuading potential donors to do something they would not otherwise choose to do.
To avoid this possibility, countries that allow embryo donation for research may attempt a strict separation of IVF treatment and the stem cell research domain. (Not all legislatures do this, however: China is one country that does not.) In the United Kingdom, for example, it is accepted good practice that requests for donation of spare embryos should not be made by the physician(s) who delivered the original IVF treatment. In Switzerland, a predominant interpretation of the current law on embryo donation is that a couple undergoing IVF treatment should not be told even of the theoretical possibility that a surplus embryo might be generated unless it actually is (Porz et al. 2008). By setting up such physical and procedural barriers, regulators hope to rule out any conflict of interest on the part of the treating physician as well as the possibility of gratitude on the part of the patient. There are several theoretical questions that can be asked about a claim that the “risk” of gratitude affects potential donors’ decisions. For example, moral psychologists might want to examine the emotional exceptionalism in which gratitude is seen as potentially compromising, while other emotions, or even the absence of emotion, is not. There is also an obvious empirical question which does not seem to have been closely examined: whether potential embryo donors actually do experience a sense of personal gratitude to the physician—or one strong enough to sway their donation decision. Our findings suggest that they do not. However, they do indicate that participants’ rationales for donation indicate a desire to “give back” in a more complex way.
First, our empirical results show the importance of distinguishing between the three moral emotions of gratitude, indebtedness, and solidarity. These three terms have overlapping meanings. What we normally mean by gratitude is an emotion primarily associated with gifts or with help that is undeserved. Gratitude has been defined as “a feeling of thankful appreciation for favours received” (Guralnik 1971, 327) and is experienced as a positive emotion. Watkins et al. (2006) provide a basis from experimental psychology for distinguishing between indebtedness and gratitude. One important distinction is that “indebtedness is an emotion of exchange, whereas gratitude is not” (Watkins et al. 2006, 236). Even if a debt of gratitude is felt, “it does not appear to be analogous to an economic debt” (Watkins et al. 2006, 239). Indebtedness, however, is, literally, a debt: a “state of obligation to repay another” (Mauss 2001, 2). A further feature associated with indebtedness but not with gratitude is the inherent imbalance of power, so that a hierarchy is created in which those who are indebted are rendered more vulnerable. The empirical social psychological work of Watkins et al. indicates that, in experimental settings at least, a person’s feelings of gratitude diminish as the expectation of return (indebtedness) increases. The more reciprocity is expected or demanded, the more indebted and the less grateful a beneficiary feels. Importantly for considering the effects of these social emotions on donation decisions, Watkins et al. found that the greater the expectation that something will be given back in return, the less motivated the participants were actually to comply with the norm of reciprocity (Watkins et al. 2006, 236). These results suggest that if patients were to sense any expectation of return by an individual physician or researcher, it would if anything lessen any gratitude they might have felt.
In the IVF context, what people have received (the thing for which they might feel grateful) is their baby or pregnancy, or at the very least, treatment. Donors who achieve this have not received a gift, but a medical service, which will have been paid for in one way or another. In Switzerland, where IVF is not covered by the mandatory health insurance, this will often be direct payment from the patients to the clinic, as it will also often be in China. In the United Kingdom, patients who do not already have children commonly receive two “free” cycles of NHS treatment (paid for through taxes on the population), and then they pay for future cycles directly through fees to the clinics. Whatever the system of payment, however, the point is that the IVF physician or clinic has already been paid, directly or indirectly, for the treatment which produced the outcome. So in the case of embryo donation, it could be argued that neither gratitude nor indebtedness should be anticipated. Gratitude would not be expected, because what patients have received was not a favour or unexpected gift; and indebtedness would not be expected, because there is no debt if payment has already been made.
In our three studies, although we found appreciation and high esteem were expressed for the work of the treating hospital or team, we found no evidence of gratitude being expressed toward an individual physician. This is despite the fact that in both the United Kingdom and China mention was made of the well-known head physicians who led each clinic; the mentions were in appreciation of their reputations, not as a debt of gratitude. Participants wanted to do something with the surplus embryo that would be of benefit to research and medical treatment for infertility, but this was not directly associated with the physician who provided it originally. Indeed, some of our interviewees were critical of aspects of their own IVF treatment, while still wanting to support the infertility research enterprise overall. In this context, it should be remembered that about half the Swiss participants interviewed in fact chose not to donate, primarily out of anxiety about losing control over the fate of their embryos, but also in some cases because it meant researchers were “getting something for nothing.” Similarly, in the U.K. study, a few patients were suspicious that research was being prioritised over treatment and that embryos might have been kept back for the research rather than frozen. Although only a small number of participants expressed this view, it has particular relevance here as it indicates clearly the absence of either gratitude or indebtedness: indeed, it suggests that these participants felt that, if anything, donation would mean the researchers were receiving something beyond their entitlement or were indebted to the patients rather than the reverse.
Social exchanges may entail giving back not to an individual, because the individual may be unknowable or because the benefit may not have come from a single identifiable person, but to “the pattern of social life” (Becker 1986)—for example, giving back to the institutional biomedical research that had helped the participants. In serial reciprocity, person A receives something from person B, but pays back not to person B but to some other third party (Moody 2008). Serial reciprocity accounts for the way that altruistic blood donors often do describe their action in terms of reciprocity, even though they have not received anything from the person to whom their blood eventually goes. What drives serial reciprocity is not gratitude or indebtedness to an individual or an organisation but a sense of solidarity with unknown others in the community.
In the case of embryo donation, what appears to be a directly reciprocal act of gratitude—a surplus embryo in return for treatment—may thus be understood as something quite different. Participants in our studies used a rationale for donation based not on reciprocal exchange between individuals, but on “giving back to” a research enterprise from which they had benefited and which they hoped would benefit unknown others in the future. For the Swiss and Chinese donors who choose to donate because they think they are supporting infertility research, these unknown others are not completely anonymous: they are “known” because of imaginatively shared experience. “Giving something back” to the research that had helped them (as they think they are doing) was not considered an obligation but, rather, a form of return that was meaningful and seemed especially fitting to them because of the experiences they had gone through. In the U.K. study, although there was greater clarity about the purpose of the research being contributed to, there was still a sense among embryo providers that they were benefiting from the fact that others had participated in research in the past which had improved IVF; they were clear in expressing solidarity with this imagined community of previous IVF research contributors by making their own contributions to research, albeit research in another domain.
At least some of our participants, then, also see their donation to research as an indirect way of passing on the benefit they have received from research to someone else, whose situation in some way resembles their own. The social meaning of this indirect reciprocity is neither gratitude nor indebtedness, but solidarity with other present and future patients.