Journal of Bioethical Inquiry

, Volume 13, Issue 3, pp 431–438 | Cite as

Intra-Family Gamete Donation: A Solution to Concerns Regarding Gamete Donation in China?

Original Research

Abstract

Gamete donation from third parties is controversial in China as it severs blood ties, which are considered of utmost importance in Confucian tradition. In recent years, infertile couples are increasingly demonstrating a preference for the use of gametes donated by family members to conceive children—known as “intra-family gamete donation.” The main advantage of intra-family gamete donation is that it maintains blood ties between children and both parents. To date there is no practice of intra-family gamete donation in China. In this paper, we investigate intra-family adoption in China in order to illustrate that intra-family gamete donation is consistent with Confucian tradition regarding the importance of maintaining blood ties within the family. There are several specific ethical issues raised by intra-family gamete donation. It may, for example, result in consanguinity and the semblance of incest, lead to confused family relationships, and raise concerns about possible coercion of familial donors. Confucian tradition provides a new approach to understand and deal with these ethical issues in a way that Western tradition does not. As a result, we suggest intra-family gamete donation could be an acceptable solution to the problem of infertility in China. However, further discussion and open debates on the ethical issues raised by intra-family gamete donation are needed in China.

Keywords

Intra-family gamete donation Intra-family adoption Confucianism Ethics Blood tie ART 

Intra-Family Gamete Donation

Assisted reproductive technology (ART) using gamete donors is widely accepted and applied in many countries. Most commonly, the donated gamete comes from an anonymous donor. In recent years, however, some infertile couples have expressed their preference for, or have already made use of, intra-family gamete donation, which involves the use of gametes from family members (Vayena and Golombok 2012). These donors may have various degrees of kin relationship to the recipient couple. Intra-family donation consists of either intra-generation donation (e.g., between siblings, cousins, or sisters- (or brothers-) in-law), or inter-generation donation (e.g., son–father, daughter–mother, or niece–aunt).

If a couple facing fertility issues makes use of a third party donor, the resulting child will be genetically related to only one of their parents. However, if a couple chooses a donor from within the family the child can have a genetic link with both parents. For many, this is a reason to prefer intra-family donation over what we will refer to as “ordinary” gamete donation, i.e. where the donor is not related to the recipient (Adair and Purdie 1996). Moreover, in cases where unrelated “third party” donors remain anonymous, the origin of the genetic material remains unknown (Baetens et al. 2000) and there is also a lack of information about the donor’s appearance and personality traits. These are additional reasons why some couples prefer a donor from within the family (Greenfeld and Klock 2004).

Intra-family gamete donation is legal and applied in many countries. Most of these countries have issued special guidelines for intra-family gamete donation, in addition to existing regulations regarding ART.1 This is because, as we will outline below, intra-family gamete donation raises specific ethical issues that are not necessarily raised with ordinary gamete donation. Although these guidelines emphasize different aspects of intra-family gamete donation, in general, they agree on the following:
  1. 1.

    The use of family members as donors is, in general, ethically acceptable;

     
  2. 2.

    First or second degree consanguinity should be ruled out (consanguinity is defined as reproduction by two genetically closely related individuals);

     
  3. 3.

    Intra-generational donation is more acceptable than inter-generational donation;

     
  4. 4.

    Undue pressure and influence on family members to become donors should be avoided;

     
  5. 5.

    All participants should be fully informed and counselled;

     
  6. 6.

    The decision of the donor should be autonomous.

     

Outline

In China, regulations regarding intra-family gamete donation do not yet exist, nor have there, as far as we know, been any actual cases in practice. However, there has been some discussion about, and a general interest in, this practice since a case of intra-family gamete donation in the Netherlands appeared in Chinese media (Information Times 2012). Some neighbouring countries have already reported cases of intra-family gamete donation. For instance, in Taiwan a woman donated her oocyte to her infertile elder sister (Cheng 2006) and in Japan 110 women used sperm donated by their fathers-in-law to conceive 118 babies (Jiang 2014).

In this paper, we argue that intra-family gamete donation could offer an acceptable solution for infertile couples in China who wish to have a child but who find ordinary artificial insemination by donor (AID) controversial. This is, as we will argue below, because intra-family donation is more in accordance with traditional Confucian values than ordinary AID. Moreover, Confucian tradition allows us, more than does Western tradition, to deal with potential problems associated with intra-family gamete donation. We will begin by arguing why we think that in China, intra-family gamete donation might be more acceptable than ordinary gamete donation. We will then explain why we think that Confucianism allows us to better deal with some ethical issues raised by intra-family gamete donation than Western culture does.

Infertility in China and Confucianism

Though infertility is regarded as a problem in many cultures, in China this is particularly the case because of the central importance traditionally accorded to blood ties within the family. To understand this, we need to look deeper into Chinese traditional culture, which has been profoundly influenced by Confucianism.

Confucianism is a virtue-based ethical and philosophical system that originated about three thousand years ago. It provides not only major moral guidance for relationships between individuals but also guidance for relations between individuals and society and between humans and nature. Confucianism has deeply influenced the ideology, beliefs, and value systems of Chinese people and plays a key role in their everyday lives. However, in contemporary China, with an increasing opening-up to the outside world, western philosophical and political concepts have been introduced. New technologies and the booming economy in the last three decades have drastically changed the lifestyle of Chinese people. In this context, doubts have been raised about whether Confucianism as a traditional culture is capable of dealing with new problems in contemporary China and it has been suggested that Confucianism might need to be revised in light of these recent developments (Chen 2015). However, even if Confucianism were to be revised, it is likely that its central concepts, including filial piety, ren, li, and harmony, which have significantly influenced Chinese culture, would be preserved. We will explain these concepts and discuss how they are relevant to discussing ethical issues raised by intra-family gamete donation.

Filial Piety and the Importance of Blood Ties

Why is ordinary artificial insemination by donor controversial in China? Within the tradition of Confucianism, the central principle is filial piety, which can be best described as a virtue related to respect for one’s parents and ancestors. Procreation has always been considered a crucial aspect of filial piety. Mencius, who is the most famous Confucian after Confucius himself, stated in his classic Confucian work that “There are three things which are un-filial and to have no offspring is the greatest of them” (The book of Menciusn.d., Book IV, Part 1, Chapter xxvi ). The reason why procreation has always been regarded as so important within Confucianism can be brought back to the importance it accords to blood ties within the family. Moreover, what has traditionally been considered of utmost importance is to have male offspring, as it was for a long time believed that only men were able to continue the family name. In fact, it was considered a man’s duty to have sons for this reason. Women had the duty to bear their husband’s son(s) so as to help him fulfil his duty. Thus, the tradition of filial piety focuses strongly on the genetic link between father and child (Li and Lu 2005). In contemporary China, blood ties are still considered very important because of this tradition, though now the genetic link between parent and daughter is also valued.

The importance accorded to blood ties is the main reason why ordinary AID is controversial in China. On the one hand, it can help infertile couples to fulfil their wish to have a child that is genetically related to one of the parents. On the other hand, it severs the genetic link between the other parent and the child (Qiu 2002; Heng 2009; Liao, Dessein, and Pennings 2010). Thus, AID deeply infringes on traditional Confucian views on family lineage (Liao, Dessein, and Pennings 2010).

The Tradition of Li-Si and Intra-Family Adoption

Another, related, Chinese tradition that is relevant to the controversy surrounding donor gametes is intra-family adoption. Intra-family adoption in China is based on the Li-Si tradition and started more than three thousand years ago (Ding 2009). “Li” is explained as the verb “establish,” and “Si” implies “inheritor.” Already in feudal China (221BCE–1912CE), having a son was extremely important as, indeed, the son was seen as the carrier of the family blood line. Moreover, the oldest son was the inheritor of the family’s social status and properties, and had to serve his ancestors. Paying homage to and worshipping ancestors were extremely important rituals in ancient China (Ding 2009). If a couple had no son, they were allowed to adopt a son from relatives, and this son then became the inheritor (Ding 2009; Song 2009). First, the couple had to try to adopt a son from one of the husband’s brothers. However, if this was not possible, then the couple had to try to adopt a son of the husband’s more distant relatives. A couple was, however, not allowed to adopt a son with a different family name. In addition, a family could not give away their eldest son for adoption (Ding 2009). However, Li-Si was not the only form of intra-family adoption. In folk custom, there were forms of intra-family adoption that were not limited to adopting a son from the same kin with the same family name. For instance, a man could adopt his sister’s son as the inheritor. If a woman was the only daughter in a family, then her husband could be adopted as a son of the wife’s family. The practice of Li-Si was abolished by the Nanjing Kuomintang government in 1930 (Fu 2009). From then onwards, adoption in China was also allowed outside family kin.

In contemporary China, however, intra-family adoption is still favoured over other types of adoption both in relevant laws and in folk custom (Ding 2009; Fu 2009). Regulations regarding intra-family adoption are more flexible than for ordinary adoption. For example, while in ordinary adoption the adopted child must be younger than fourteen, there is no age limit for intra-family adoption (China Adoption Law 1998). It seems that Chinese people are still deeply influenced by Confucian family values and prefer a child with a stronger, rather than a weaker, genetic link to themselves. For this reason, intra-family gamete donation could be considered as more acceptable in China than ordinary gamete donation.

Intra-Family Gamete Donation Could Reduce the Scarcity Problem

Apart from being in accordance with traditional values regarding blood ties within Chinese culture, intra-family gamete donation also has the advantage that it will accelerate the process of fertility treatment. There is a worldwide shortage of gamete donors and the waiting list for infertile couples is often very long. According to the China Women’s Executive Committee, the number of infertile people in China exceeded 50 million at the end of 2011 (China Women’s Executive Committee 2011). There is a shortage of sperm as well as oocytes donors. For example, the Shandong Sperm Bank can provide donor sperm for only half of the six thousand couples that need donor sperm to conceive a child (Shandong Sperm Bank 2010). There is no oocyte bank in China. Peking University First Hospital tried to build the first oocyte bank in 2004 but, due to a lack of oocyte donors, was forced to close down. Other hospitals have been trying to build oocyte banks as well and have been confronted with the same problem (China Oocyte Bank 2014).

For those able to make use of intra-family gamete donation, seeking a gamete donor from within the family could reduce the waiting time for infertile couples overall. Since the number of donor gametes would likely increase, the waiting list would be shortened, and thus would also reduce the waiting time for those who cannot make use of intra-family gamete donation.

Thus far we have argued that, because it would be less controversial than ordinary AID, intra-family gamete donation could offer a solution for infertile couples in China who need donor gametes. In addition, intra-family gamete donation has the advantage that it would help to reduce the problem of shortage of donor gametes. In the remainder of this paper we will consider some general objections to intra-family gamete donation and will point out how Confucianism would actually provide a moral framework that would allow Chinese people to better deal with these objections than Western tradition may do.

The Ren Tradition and Concerns about Undue Inducement

In Western countries, one argument against intra-family gamete donation is that it will result in family members of the infertile couple being coerced, or at least feeling pressured, to act as gamete donors. The pressure could be either internal—a perceived obligation to help a relative—or external—pressure actually exerted by family members (Crouch and Elliott 1999). Especially in intergenerational donation (e.g., a nephew agrees to donate sperm to his uncle) there may be coercive influences on the decision-making of the donor. Whether, and to what extent, the decision to donate gametes will be made freely may depend on the donor’s perception of his or her family values, including the religious views of the donor and the relationship between donor, recipient, and other family members (Vayena and Golombok 2012).

In Western tradition, autonomous decision-making is a rights-based concept—it emphasizes individuals’ rights (Yu and Fan 2007). Nevertheless, the extreme focus on patient autonomy in Western culture has been questioned. It has been considered too narrow—ignoring other values, such as family integrity and physician responsibility (Blackhall et al. 1995). Confucian thought provides a model of decision-making that may reduce the importance of the concern regarding autonomous decision-making by family members to become a gamete donor.

According to Confucianism, a physician is required to be not only an expert in medical skills but also a “cultivated” person. As mentioned earlier, filial piety is regarded as the root of Confucian virtue. Benevolence or humaneness (ren) is considered to be a cardinal virtue. Ren is widely understood as “to love your fellow man” (Lau 1992). Physicians too must be practitioners of ren. They are expected to sympathize with their patients and to be highly concerned with their well-being. For example, if physicians judge that disclosure of a diagnosis will likely lead to psychological distress for the patient, they may decide to withhold this information. However, in such cases, unlike the paternalistic model where physicians simply make medical decisions on behalf of patients, Chinese physicians are obliged to release full information to the patient’s family (at least, those members of the family that are frequently in contact with each other). The family decides if (or to what extent) the information should be passed on to the patient, and to what extent the patient should be involved in the decision-making process regarding further treatment. In Confucian tradition, family members possess the moral authority to participate in medical decision-making that concerns a family member. This is because the family is the primary context where one starts to cultivate moral virtue—through the interaction with family members. They are believed to have a good understanding of each other’s needs, values, beliefs and life goals. Thus, it is believed that they are in a better position than physicians to judge what is in the interest of the patient (Yu and Fan 2007).

From a Confucian perspective, then, the fact that the family is involved in a family member’s decision to donate gametes will not necessarily be considered undue influence. It is normal and accepted that family members are involved in such a decision. The family is expected to, and likely will, take into account the interests of both the donor and the recipient. It remains important, however, that the issue is openly discussed within the family, and between the recipient and the donor, and that if the potential donor refuses to donate, his or her wish should be respected. To further reduce the risk of undue inducement, the donor and recipient should also receive counselling.

Since in Confucianism, it is normal and desirable for a family to take important decisions together, with the concerned party’s interests in mind, the concern of undue inducement may be accorded less weight. What is considered undue inducement in Western countries might not be considered undue inducement within Confucian culture.

Confucian culture would also provide family members with a motivation to donate their gametes to help a family member. Ren in Confucianism is not a concept of egalitarian love but varies according to different subjects. Benevolence towards close family members must be reciprocated, for family is where we first interact with people and experience affection and care (Yu and Fan 2007). Then love can be extended to others to whom we are more distantly related. It would therefore, according to Confucian values, be the morally correct thing to do for family members to try to relieve the suffering of infertile relatives and help them substantially by offering to donate gametes. As a result, donors may experience a feeling of fulfilment as they contribute to maintaining the kin blood relationship, which is an extremely important value within Confucianism. This in turn could strengthen the link between family members and enhance the feeling of family solidarity. Given the central place of the family in Confucian society, these are important values for Chinese families influenced by Confucian thought. Donors would feel more satisfied with themselves, for by altruistically meeting the needs of other family members to create a family, the donors’ moral virtue with respect to ren is also cultivated.

Concerns about Genetic Disease and Incest

Some might object to intra-family gamete donation because they fear that it will result in an increased incidence of genetic disease. Sexual relations and marriages between certain genetically related individuals are legally banned in many countries in order to reduce the risk of birth defects and social disorder or conflict. For this reason, Chinese marriage law prohibits incestuous relationships and consanguinity. It stipulates that closer than third-degree (genetic) relatives are not allowed to marry each other (China Marriage Law 2001).2 However, these laws would not prohibit intra-family gamete donation, as it does not involve sexual relations or marriage. Moreover, to avoid consanguinity, intra-family donation could simply be restricted to relatives that are at least third-degree relatives (De Wert et al. 2011).

Though intra-family gamete donation does not involve incest, since it does not involve any sexual relations, some might nevertheless mistakenly associate intra-family gamete donation with incest. A concern exists that, because of the enormous taboo on incest in China, family members might refuse to get involved in intra-family gamete donation. However, it is reasonable to expect that these gut feelings, which are based on mistaken beliefs about incest, would disappear, or diminish, with information campaigns about intra-family gamete donation. Potential donors and recipients should be informed about the fact that such donation does not involve sexual relations and hence has nothing to do with incest.

The Principle of Li and Concerns About Confused Family Relationships

Another concern that has been expressed regarding intra-family gamete donation is that because the donor is a family member, intra-family donation would cause confusion about family roles. For instance, in sister-to-sister oocyte donation, the rearing mother is a genetic aunt of the child, while the rearing aunt (the donor) is the genetic mother. In father-to-son sperm donation, the rearing father is the child’s genetic half-brother, while the genetic father is the rearing grandfather. In the case of daughter-to-mother oocyte donation, the rearing mother is actually the genetic grandmother, and the genetic mother is the child’s half-sister. These complicated relationships raise certain concerns. If the genetic origin of the child is disclosed, the child may be confused about different family members’ social role and this may negatively affect her identity.

This raises questions about (i) whether and if so, when, it should be disclosed to the child that she was conceived with an intra-family donor gamete, and (ii) whether, and if so, how clear boundaries should be drawn between the donor and the recipient family. (Boundary here means to what extent the donor could be involved in the recipient couple’s family life.) How these questions are dealt with will profoundly affect relationships between donor, recipient, and child (Vayena and Golombok 2012).

There are several reasons why a recipient couple may be reluctant to tell the child about her conception with a family member’s gamete: they may be worried that when the child knows this, she will love them less or that the complexity of the family relationships will negatively affect the child, and their relationship with the child. Some have suggested that secrecy protects the donor child from social or psychological problems and helps to maintain stable family relationships (Cook et al. 1995; Xu 1999; Murray and Golombok 2003; Van Den Akker 2006).

However, it is suggested that disclosure is recommended in intra-family gamete donation (Vayena and Golombok 2012). First, it is believed that donor children have the right to know their genetic origins. Second, disclosure is recommended because the child might find out himself, for example by noticing a resemblance between himself and his donor or the donor’s own child, or by accidently finding out the truth from another family member. This is likely to be worse for the child than if the parents had informed her (Adair and Purdie 1996; Frith 2001; Daniels, Grace, and Gillett 2011). It has been suggested that it is in the interest of the child for the parents to disclose her genetic origin when she is young (Rumball and Adair 1999; MacDougal et al. 2007; Jadva et al. 2009; Blyth, Langride, and Harris 2010). The earlier the child is told about the way she was conceived, the easier she is likely to integrate this information into her sense of self (Vayena and Golombok 2012). Children conceived with donor gametes who are told or find out the truth in adolescence or later in life are more likely to feel deceived and distressed as a result (Turner and Coyle 2000; Jadva et al. 2009). However, there are as yet no reliable studies on the impact of disclosure on the donor’s children (Yee, Blyth, and Ka Tat Tsang 2011).

Questions have been raised about boundaries between family members’ roles, for example, about the extent to which the donor could or should be involved in the recipient couple’s (nuclear) family life. Intra-family gamete donors might feel they have parental responsibilities and wish to be involved in the child’s life (Weinberg 2008). Especially if there is a resemblance, a donor might feel that to some extent the child is his “own” (Vayena and Golombok 2012). Legally, however, they do not have parental rights. Gamete donors might also want to avoid any involvement in raising the child. They might be worried that this will nevertheless be expected from them. It is thus of great importance that the donor and the recipient, and other involved family members, come to an agreement regarding the involvement and responsibilities of the donor.

In China, it is currently illegal to reveal the identity of a third party gamete donor. This legislation finds its roots in prevailing cultural norms regarding the importance of maintaining blood ties within the family. To have unacknowledged biological offspring is typically considered an insult to one’s family and ancestors. It is thus not surprising that the recipient’s family typically tries to keep the child’s genetic origins a secret (Liao, Dessein, and Pennings 2010). However, in intra-family donation, the source of genetic material is very clear and blood ties are not severed. Thus, there would be less reason for keeping the genetic origin of the child a secret.

In China, family relationships are ruled by the Confucian principle called li. Li requires that family members strictly play their own social role (e.g., a son cannot take his father’s position to decide something, and a younger son cannot replace his elder brother to fulfil some tasks). The rules of li could greatly help to reduce concerns about complex family roles in the context of intra-family gamete donation. It is generally accepted that everyone has to strictly perform and follow the rights and obligations attached to their social roles. Li emphasises harmony. There is a Chinese saying: “If the family live in harmony, all affairs will prosper.” Confucius pointed out: harmony is the essential part of ritual application (Lau 1992). The interaction between all social roles should be harmonious. Thus, if there is a conflict about the donor’s involvement in the recipient couple’s (nuclear) family life, both parties are expected to, and will likely make a compromise that is in the best interest of the child. Moreover, as mentioned earlier, within a Chinese family, family members are generally significantly involved in each other’s lives. Thus, if the donor wants to be involved in the life of the donor-child, this would not be a serious issue in intra-family donation in China. Suppose the gamete donor were the aunt of the child, this aunt could be closely involved in the child’s life, as many aunts in China are. The nuclear family would not be threatened, as the role of an aunt has clear boundaries. Thus, in the collective circumstances within a family, li can help to cope with the potential problem of role confusion in the context of intra-family gamete donation.

Conclusion

Intra-family gamete donation is a new type of assisted reproductive technology in contemporary China. The practice is, however, relatively unknown and many may have concerns regarding its ethical acceptability. However, we have argued that intra-family gamete donation would be consistent with Confucian culture in which kin blood ties are considered of utmost importance. We have argued that, compared to artificial insemination by donor with a third, unrelated party, intra-family gamete donation would likely be considered more acceptable for infertile couples who wish to have a child in China, as it maintains the genetic link between the child and both parents. Moreover, it has the advantage of shortening waiting lists for donor gametes. Intra-family gamete donation also raises thorny ethical issues. However, we have shown that Confucian culture allows us to deal with these issues in a way that Western culture does not, or does to a lesser extent. The problem of consanguinity can be avoided by restricting intra-family gamete donation to family members of at least the third degree. The issue of undue inducement by family members would likely be seen as less problematic in societies influenced by Confucianism, as it is widely accepted that family members take important family decisions collectively. Furthermore, the problem of confused family relationships is also less serious, as the rules of Confucian li, which instructs family members to strictly keep to their role, can help to make these roles less confusing even in the context of the heavy involvement of extended family members in children’s lives that is standard in Confucian culture. Thus, if the gamete donor would like to be involved in raising the child in some way, this would typically not be considered problematic. We think that, given the influence of Confucianism in contemporary China, intra-family gamete donation could be an acceptable solution for infertile couples that wish to have a child but find ordinary gamete donation morally problematic. However, further discussion and open debates on the ethical aspects of intra-family gamete donation are needed in China.

Footnotes

  1. 1.

    For example, in the United States in 2003, the American Society for Reproductive Medicine (ASRM Ethics Committee) published a report entitled Using Family Members as Gamete Donors and Surrogates (ASRM Ethics Committee 2003). In 2007 in New Zealand, the Advisory Committee on Assisted Reproductive Technology (ACART) issued the Guidelines on Donation of Eggs or Sperm between Certain Family Members (ACART 2013). In the UK, the Human Fertilisation and Embryology Authority (Hamm) issued specific regulations in 2009 based on a paper on intergenerational gamete and embryo donation (Hamm 2009). In 2011, a guideline was issued by the European Society for Human Reproduction and Embryology´s Task Force on Ethics and Law (ESHRE Task Force on Ethics and Law 2011).

  2. 2.

    Human genetic relations can be classified into first degree (sibling, parent, and child), second degree (aunt, uncle, niece, and nephew) and third degree (cousin) (De Wert et al. 2011).

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Copyright information

© Journal of Bioethical Inquiry Pty Ltd. 2016

Authors and Affiliations

  1. 1.Department of Philosophy and Moral SciencesGhent UniversityGentBelgium
  2. 2.Oxford Uehiro Centre for Practical EthicsUniversity of OxfordOxfordUK

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