The Ethics of Stem Cell-Based Embryo-Like Structures : A Focus Group Study on the Perspectives of Dutch Professionals and Lay Citizens.

In order to study early human development while avoiding the burdens associated with human embryo research, scientists are redirecting their efforts towards so-called human embryo-like structures (hELS). hELS are created from clusters of human pluripotent stem cells and seem capable of mimicking early human development with increasing accuracy. Notwithstanding, hELS research finds itself at the intersection of historically controversial fields, and the expectation that it might be received as similarly sensitive is prompting proactive law reform in many jurisdictions, including the Netherlands. However, studies on the public perception of hELS research remain scarce. To help guide policymakers and fill this gap in the literature, we conducted an explorative qualitative study aimed at mapping the range of perspectives in the Netherlands on the creation and research use of hELS. This article reports on a subset of our findings, namely those pertaining to (the degrees of and requirements for) confidence in research with hELS and its regulation. Despite commonly found disparities in confidence on emerging biotechnologies, we also found wide consensus regarding the requirements for having (more) confidence in hELS research. We conclude by reflecting on how these findings could be relevant to researchers and (Dutch) policymakers when interpreted within the context of their limitations.

Intrafamilial oocyte donation in classic galactosemia: ethical and societal aspects.

Classic galactosemia is a rare inherited disorder of galactose metabolism. Primary ovarian insufficiency (POI) with subfertility affects > 80% of female patients and is an important concern for patients and their parents. Healthcare providers are often consulted for subfertility treatment possibilities. An option brought up by the families is intrafamilial oocyte donation (mother-to-daughter or sister-to-sister). In addition to POI, galactosemia patients can also present varying cognitive and neurological impairments, which may not be fully clear at the time when mother-to-daughter oocyte donation is considered. Ethical and societal aspects arise when exploring this option. This study aimed to provide guidance in aspects to consider based on the views of different groups involved in the oocyte donation process. A qualitative study using in-depth semi-structured interviews with > 50 participants (patients, family members, and healthcare providers) was conducted. From these interviews, themes of concern emerged, which are illustrated and reviewed: (1) family relations, (2) medical impact, (3) patients' cognitive level, (4) agreements to be made in advance and organization of counseling, (5) disclosure to the child, and (6) need for follow-up. We conclude that discussing and carrying out intrafamilial oocyte donation in galactosemia patients requires carefully addressing these themes. This study adds value to the already existing recommendations on intrafamilial oocyte donation in general, since it highlights important additional aspects from the perspectives of patients and their families.

[Making embryos for research: first prohibited, now allowed?] / Embryo's maken voor onderzoek: eerst niet, nu wel?

The Dutch Embryos Act (2000) contains a temporary ban on the creation of embryos for research, meaning that, at present, only research using "spare" IVF embryos is allowed. Recently, the government has announced a plan to lift this ban. This is in line with the original intention of the Act, which already contains conditions for research with specially created embryos that will come into force after the lifting of the ban, including the restriction that the research must be expected to yield new insights in the domains of infertility, assisted reproduction, hereditary or congenital disorders, or transplantation medicine. The government plans announced allow research only in the first three of these domains, adding the further criterion that the research must be 'directly relevant for clinical application'. According to the government, the reason for these additional restrictions was the need to protect 'human dignity'. The authors of this paper are not convinced.

[Foetal therapy for Down syndrome: a pro-active ethical reflection]. / Foetale therapie voor het Down-syndroom.

Prenatal screening for Down syndrome has to date focused on facilitating the informed choice to continue or not with a pregnancy. The non-invasive prenatal test (NIPT) for Down syndrome does potentially offer the option to apply foetal neurocognitive therapy for Down syndrome (FTDS). Current research in animal models looks promising and therefore a proactive ethical reflection in relation to clinical trials is urgently needed. This discussion includes an exploration of the ethical aspects of FTDS. There seem to be no convincing a priori objections on the basis of the social model of disability. Arguments in terms of (respect for) autonomy, wellbeing and justice seem to in principle support such therapy. Still, both the conditions for sound clinical trials and the implications of possible effective therapy for current prenatal screening need further scrutiny.

Genomic futures of prenatal screening: ethical reflection.

The practice of prenatal screening is undergoing important changes as a result of the introduction of genomic testing technologies at different stages of the screening trajectory. It is expected that eventually it will become possible to routinely obtain a comprehensive 'genome scan' of all fetuses. Although this will still take several years, there are clear continuities between present developments and this future scenario. As this review shows, behind the still limited scope of screening for common aneuploidies, a rapid widening of the range of conditions tested for is already taking shape at the invasive testing stage. But the continuities are not just technical; they are also ethical. If screening for Down's syndrome is a matter of providing autonomous reproductive choice, then why would providing the choice to have a full fetal genome scan be something entirely different? There is a clear need for a sustainable normative framework that will have to answer three challenges: the indeterminateness of the autonomy paradigm, the need to acknowledge the future child as an interested stakeholder, and the prospect of broad-scope genomic prenatal screening with a double purpose: autonomy and prevention.

Reproductive options for prospective parents in families with Huntington's disease: clinical, psychological and ethical reflections.

BACKGROUND Huntington's disease (HD) is an autosomal dominant neurodegenerative late onset disorder. This review of reproductive options aims to increase reproductive confidence and to prevent suffering in relation to family planning around HD and possibly other late onset neurodegenerative disorders. METHODS Selected relevant literature and own views and experiences as clinical geneticists, psychologists and ethicists have been used. RESULTS Possible options, with emphasis on prenatal diagnosis (PD) and preimplantation genetic diagnosis (PGD) to prevent the transmission of HD to the next generation, are described and discussed. They are formally presented in a decision tree, taking into account the presence or absence of a fully penetrant allele (FPA), a reduced penetrant allele (RPA) or an intermediate allele (IA). A table compares invasive and non-invasive PD and PGD. From a psychological perspective, the complex process of counselling and decision-making regarding reproductive options is discussed. Special attention is paid to the decision to avoid the transmission of the mutation and to the confrontation and coping of a mutation-free child growing up with a parent developing disease symptoms. From an ethical point of view, reflections on both PD and PGD are brought forward taking into account the difference between FPA, RPA and IA, direct testing or exclusion testing and taking into account the welfare of the child in the context of medically assisted reproduction. CONCLUSION Recommendations and suggestions for good clinical practice in the reproductive care for HD families are formulated.

Evaluation of exclusion prenatal and exclusion preimplantation genetic diagnosis for Huntington's disease in the Netherlands.

Individuals at 50% risk of Huntington's disease (HD) who prefer not to know their carrier status, might opt for exclusion prenatal diagnosis (ePND) or exclusion preimplantation genetic diagnosis (ePGD). This study aims to provide a better understanding of couples' motives for choosing ePND or ePND, and surveys couples' experiences in order to make recommendations for the improvement of counselling for exclusion testing. This qualitative retrospective interview study focussed on couples who underwent ePND or ePGD for HD in the period 1996-2010. Seventeen couples were included of which 13 had experienced ePND and 6 ePGD. Mean time-interval since exclusion-testing was 3.9 years. Couples' moral reservations regarding termination of pregnancy (TOP) or discarding healthy embryos were counterbalanced by the wish to protect their future child against HD. Seven couples had terminated a total of 11 pregnancies with a 50% HD risk, none showed regret. ePGD was used by couples who wanted to avoid (another) TOP. ePND and ePGD are acceptable reproductive options for a specific group of counsellees. To guarantee sound standards of care, it is imperative that candidate couples be given in-depth non-directive counselling about all possible scenarios, and adequate professional and psychological support prior to, during and after ePND/ePGD.

Preimplantation genetic diagnosis.

Pre-implantation genetic diagnosis (PGD) is generally defined as the testing of pre-implantation stage embryos or oocytes for genetic defects. It has been developed for couples whose potential offspring are at risk of severe Mendelian disorders, structural chromosome abnormalities or mitochondrial disorders. Pre-implantation embryo diagnosis requires in vitro fertilization, embryo biopsy and either using fluorescent in situ hybridization or polymerase chain reaction at the single cell level. Therefore, it is a complex procedure which requires much experience. Aneuploidy screening to improve medically assisted reproduction (in vitro fertilization/intracytoplasmic sperm injection) is a variant type of PGD. The past, present and future of this development are strongly related to the natural occurrence of chromosomal mosaicism in the pre-implantation embryo. PGD should be included in each reproductive health care programme. It is recognized as an important alternative to pre-natal diagnosis. However, diagnosis from a single cell remains a technically challenging procedure, and the risk of misdiagnosis cannot be eliminated. An ethical discussion of the question of whether PGD is acceptable at all-the 'desirability question'-is a rearguard action. Discussion must primarily focus on the conditions of exercising due caution in and the dynamics of PGD.

Fertility preservation for healthy women: ethical aspects.

There is currently much debate about cryopreservation of ovarian tissue or oocytes as a possible means of fertility preservation for women urgently needing potentially sterilizing medical treatment. Although both techniques are still experimental, some centres have started offering them also to healthy women who want to postpone childbearing until after they may have lost their natural reproductive capacity, or fear that they may not before that time find a partner with whom to raise a family. This article explores and discusses the ethical issues raised by this practice. We argue that there are no convincing a priori moral reasons why cryopreservation of ovarian tissue or oocytes should not also be available for healthy women. However, this is on the assumption of established techniques, also in terms of the efficient and safe use of any frozen reserve. The fact that there is still uncertainty about these aspects is rightly seen as a reason for only offering cryopreservation of ovarian tissue or oocytes in an experimental setting. But does that also mean that these techniques should presently only be available for a medical reason, i.e. for women facing iatrogenic fertility loss? We argue against this conclusion.

[Medicinal management of pain and symptoms following the withdrawal of treatment in babies and children]. / Medicamenteuze pijn- en symptoombestrijding bij het staken van de behandeling bij pasgeborenen en kinderen.

We present three cases to illustrate the end-of-life care after withdrawal of mechanical ventilation. In a one-year-old girl with meningococcal septic shock, muscle relaxants were continued when mechanical ventilation was withdrawn. In a 10-day-old girl with perinatal asphyxia a high dose of fentanyl was given before mechanical ventilation was withdrawn. A 6-week-old girl in a vegetative state was fighting for breath after detubation. At the request of the parents to end this condition, vecuronium bromide was given. In these three cases death was probably brought forward by a maximum of 12-24 hours. Three arguments can be presented to justify this: the relief of suffering, the perceptions of the parents and the fact that death was expected within a very short time. The administration of these medicines cannot, however, be considered normal medical practice. Therefore we argue that these cases should be reviewed by the national expert review committee and guidelines should be developed for appropriate palliative care after the withdrawal ofmechanical ventilation.

[Genetic cancer syndromes and reproductive choice: dialogue between parents and politicians on preimplantation genetic diagnosis]. / Erfelijke kankersyndromen en kinderwens: ouders en politiek in dialoog over pre-implantatiegenetische diagnostiek.

Genetic cancer syndromes have identical clinical severity, limited therapeutic options, reduced life expectancy, and risks of genetic transmission, as do other genetic or congenital diseases for which prenatal genetic diagnosis or preimplantation genetic diagnosis (PGD) is allowed in the Netherlands. That was implied in the certification of one Dutch PGD centre at Maastricht University Hospital by the Dutch Ministry of Health, Welfare and Sport in 2003. A report by the Health Council of the Netherlands in 2006 confirmed this view with scientific and ethical evaluation. However, in 2006 the State Secretary for Health strongly objected to PGD for cancer, and disease risks of 50-100% for gene carriers, i.e. for highly, but not always fully penetrant genes. In 2006, the Maastricht centre discontinued PGD for cancer and couples were referred to other countries; prenatal genetic diagnosis remained available, however. On 26 May 2008, the present State Secretary proposed to parliament that the Health Council of the Netherlands report from 2006 be followed. This once again clashed with the fears of some Christian parties for a slippery slope and embryo selection for 'only a risk and not certainty of disease'. Yet no firm evidence for the existence of such a slope has been found. The Dutch framework for handling the ethical and medical evaluation of new reproductive and genetic technologies by the Health Council of the Netherlands Advisory Committees, professional and patient organisations, and the Ministry, has functioned for over 30 years without leading to any wrongdoing. There is no actual need for a new government body to license genetic tests on a case-by-case or per disease basis.

[Pregnancy at a later age with the help of oocyte donation]. / Zwangerschap op oudere leeftijd door middel van eiceldonatie.

An increasing number of women are delaying childbirth until an age when their fertility has significantly declined. Oocyte donation provides the opportunity for women to successfully conceive regardless of age. In The Netherlands, in 1997 the age limit for oocyte donation treatment was set at 45 years. The most important objections to pregnancy in older women are the medical risks for mother and child, the application of fertility treatments beyond the natural reproductive age and the psychosocial consequences for the child. However, based on international experience and recent data concerning the risks of pregnancy after oocyte donation in older women, it is proposed to increase the maximum age limit for this procedure to 50 years.

[Neonatal screening: dynamics and ethics]. / Neonatale screening: dynamiek en ethiek.

The Health Council of the Netherlands recently published a thorough report on neonatal screening, which recommends screening newborns for i8 treatable conditions. The report rightly stresses the importance of informing parents adequately, preferably during pregnancy. Issues that require further debate include neonatal screening for untreatable conditions and the relative advantages and disadvantages of screening newborns compared with screening prospective parents for carrier status, which may prevent the birth of a first-affected child.

[Mental competence in the context of deep brain stimulation]. / Wilsbekwaamheid in de context van elektrostimulatie van de hersenen.

In a case of Parkinson's disease, the patient was treated with deep brain stimulation of the subthalamic nucleus (STN-DBS). STN-DBS affected the mental competence of the patient and ethical questions were raised about the decision as to the direction of further treatment. The patient was asked for his opinion on the therapeutic options during a phase of non-stimulation and chose to be stimulated and admitted to a psychiatric hospital because of mental incompetence rather than remaining unstimulated, mentally competent but bedridden. Developments in the neurosciences (including STN-DBS) raise a number of different fundamental (theoretical and philosophical) as well as practical questions. STN-DBS can have various unintended (behavioural) effects. In the case presented, more weight was rightly given to the mental competence of the unstimulated patient, although comments can be made with regard to his decision making, as his choice was made in a phase of serious distress. Attention is paid to the relevance of a so-called self-binding directive. STN-DBS is not morally neutral and the case involves a tragic dilemma: a conflict between irreconcilable duties for the physician. The further development and proliferation of STN-DBS requires caution and moral deliberation. It remains important to search for alternative treatment strategies with less undesirable side effects.

[Comments on the Dutch Institute for Health Care Improvement's standard code of practice entitled, "Donation of fetal tissue"]. / Opmerkingen bij het CBO-modelreglement 'Terbeschikkingstelling van foetaal weefsel'.

Under the auspices of the Kwaliteitsinstituut voor de Gezondheidszorg CBO [Dutch Institute for Healthcare Improvement] a standard code of practice was developed as a template for local institutional codes to implement the Law on Foetal Tissue. It is a useful model code, but arguments should have been outlined more explicitly, notably in instances where the code adopts a somewhat stricter position than the Law. The following remarks pertain to the model code: 1. It may be argued that the inclusion or exclusion of 12-15-year-old pregnant girls should be relative to the privacy-related sensitivity of the use of foetal tissue. 2. Transplantation requires additional tests for the safety of the recipient, including testing for HIV/AIDS. A pregnant woman's permission for such testing should not be taken for granted. 3. The abortion technique may be modified in view of the subsequent use of foetal tissue if the woman consents to the modification, with the prerequisites that the modification does not harm the woman and that any potential sensation of pain by the foetus must be minimised.

[Cloning: applications in humans 1. Technical aspects]. / Kloneren: toepassingen bij de mens 1. Technische aspecten.

The successful cloning experiments in mammals such as the sheep and mouse prompted speculations on clinical application in humans. Cloning is possible by nucleus transplantation and by embryo splitting. Nucleus transplantation does not result in a genetically completely identical individual because the mitochondrial DNA originates from the ovum donor. Embryo splitting may be regarded as the artificial production of a monozygotic multiplet. Possible applications of cloning in humans belong in the context of reproduction (treatment of couples with subfertility, with genetic problems or with a 'replica motive'), transplantation of genetically identical tissue, and scientific research.