The primary aim of this book is to codify the risks of reproductive technologies, both for children and for society. In the process, health law professor Philip Peters defines the obligations of society, parents, physicians, other health care providers, and the children themselves in dealing with the issues raised. The process must begin with an analysis of the word "risk," which is derived from the Italian rischiare and means "to dare." Essentially, all the parties that are cited above embark on a dare when conception occurs, since the outcome is always in doubt, even though perfection is anticipated. Is the real risk greater for parents of children who are created as a result of the new reproductive technologies than it is for any two people who decide to conceive a child? During the Renaissance, when numbers were attributed to various scenarios, the measurement of risk approached the level of science. Today, risk is not only a combination of numbers but also the result of definitions derived on the basis of increased scientific sophistication. Therefore, it is difficult to deal with the issues associated with the new reproductive technologies without delving into the realm of mysticism. In this regard, Peters pays attention to both objective and subjective matters, with a proper emphasis on the former. A real scenario provides an example: a 38-year-old woman is in her fourth cycle of in vitro fertilization. The three previous cycles have failed. Each time the regulated number of embryos were implanted, according to the guidelines of the American Society for Reproductive Medicine. The patient now has five good embryos left. How many should be implanted? Should her physicians implant all five to optimize success, which would run the risk of higher-order multiple gestations (triplets or greater) and the hyperstimulation syndrome, or should they implant two and freeze three, which would increase the chance of a fourth failure to conceive for this couple? Should they perform a blastocyst transfer, which would help to correct the number of offspring but risk the loss of some good embryos incubating over time? Should they perform a preimplantation biopsy to determine why so many attempts have failed and to ensure that they are putting back "perfect" embryos? If there were no financial constraints, the decision would be easier, but this couple has already invested $30,000 in their dream of having a family. In an analytic fashion, Peters puts this scenario -- and future ones like it -- in perspective before he proposes possible solutions. This is an important book because it emphasizes that regulation and laws are necessary with regard to assisted reproductive technology. An example of why that is so is the rapid expansion of the list of diseases that can be tested for and eventually treated before implantation. As Peters contends, "The issue surfaced because our expanding scientific capacity routinely outstripped our moral bearings." Broad topics are addressed here: the interest of future children, reconciling conflicting interests, and applying a framework for decision making (ranging from high-level decisions to more mundane ones that couples are faced with in regard to reproduction). Peters's deconstruction of these issues provides a helpful framework for understanding this extremely complicated and profound topic, an analysis that even weighs the ultimate question, "What is the risk of never having existed at all?" Peters provides a dispassionate discussion of ways in which future children can be harmed by reproductive technology, a litany that he breaks down into ordinary harm (e.g., being born to a mother who took diethylstilbestrol during pregnancy), harm caused by the use of a risky reproductive procedure rather than a safer technique, and harm caused by catastrophic injury to the fetus. In this regard, the book offers a detailed examination of the moral status of the embryo, a timely issue given the choices facing modern society. The author attempts to reconcile conflicting points of view by proposing a structure for the regulation of reproductive technology. Legislation, he believes, will be based on credible evidence of harm to future children and will be drawn as narrowly as possible, deferring as much as conscience permits to "reproductive freedom." His proposal for model legislation on the basis of precedent is an extremely provocative and strong feature of the book, and the discussion of reproductive liberty versus due process is well focused. In a chapter titled "The State's Interest in Protecting Future Children," he looks at the controversy regarding the theoretical risks of cloning or genetic engineering for trait selection. These are issues that are now in the forefront of the debate and represent dramatic changes that could affect humanity. This is an important book for clinicians in reproductive medicine to read, since it will challenge their faith that good science will always prevail, that self-regulation is all that is needed, and that society should respond to new technologies in a retroactive, not a proactive, way. Couples and the physicians who are treating them are often so fixated on results that they may feel that the regulation of reproductive technology imposes unfair restrictions. The book strongly argues that legislation and regulation are essential if the powerful tool of reproductive technology is to benefit all of humanity in a safe and responsible fashion. The author describes his "tripartite framework" in order to define bad outcomes with regard to the new technologies and proposes administrative review and comprehensive oversight. In support of the current system, he describes the efforts of the Validation and Oversight Committee of the American Society for Reproductive Medicine, the Society for Assisted Reproductive Technology, and the Centers for Disease Control and Prevention to deal with the challenges. At the very end of the book, the author compares the physician who implants too many embryos with the Raelians, who claim to have cloned a human being and to have been visited by UFOs. With this comparison, the author may be unmasking some of his latent hostility in what appears to be an otherwise objective assessment of new reproductive science. Peters's take-home message is this: when scientific advances outstrip moral convictions (even among some practitioners), proactive legislation is necessary for the protection of all parties. In making its arguments, this book subtly erases the line between law and ethics. Alan H. DeCherney, M.D.
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