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Unpacking the 'Spare Embryo' : Facilitating Stem Cell Research in a Moral Landscape
Mette N. Svendsen and Lene Social Studies of Science 2008 38: 93 Koch DOI: 10.1177/0306312707082502 The online version of this article can be found at: http://sss.sagepub.com/content/38/1/9 3 Published by:
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ABSTRACT In 2003 it became legal to carry out human embryonic stem (hES) cell research in Denmark using embryos that are considered ‘spare’ in connection with fertility treatment. The public debate preceding the change of the Fertility Act presented the ‘spare’ embryo as a biological fact and discussed whether it was possible and morally acceptable to connect a given stock of ‘spare’ embryos to the stem cell lab. This paper tells a different story. Based on ethnographic fieldwork in aertility clinic in Copenhagen and among stem cell researchers, we argue that f ‘spare’ are not straightforward biological facts. Rather, complex decision-making embryos processes constitute embryos as ‘spare’ and thus as possible objects of exchange between couples in fertility treatment, stem cell researchers and future citizens in of regenerative medicine. The ongoing fact-making of the ‘spare’ embryo in need the fertility clinic reveals the network of relationships and conflicting responsibilities in which clinicians are positioned. Using the spatial metaphor of a moral landscape we explore how clinicians try out new moral pathways when seeking alternative ways to obtain and classify embryos as ‘spare’. We argue that changing moral landscapes and ‘spare’ embryos are being co-produced in the development of hES cell research. Keywords donation, IVF, moral landscapes, organizational relations, spare embryos, stem cell research

Unpacking the ‘Spare Embryo’: Facilitating Stem Cell Research in a Moral Landscape
Mette N. Svendsen and Lene Koch
A vital precondition for conducting human embryonic stem (hES) cell research is getting access to human embryos. Today there are a number of ways for accessing such embryos, depending on national regulations. general political climate in the European Union (EU) Although the is strongly sceptical of the use of embryos for hES cell research, a few European such as Sweden, Belgium and the UK, have liberalized their countries, legis- in this field, allowing for research on spare embryos from fertility lation treat- as well as embryos donated by fertile women or artificially ment, created cell nuclear transfer (CNT). Although Denmark has not gone through as as these countries, some liberalization has taken place: for example, far in Denmark legalized research using embryos that are considered spare or 2003

Social Studies of Science 38/1 (February 2008) 93–110 © SSS and SAGE Publications (Los Angeles, London, New Delhi and Singapore) ISSN 0306-3127 DOI: 10.1177/0306312707082502 www.sagepublications.com

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‘surplus’ in connection with fertility treatment (Ministry of Internal Affairs,As a consequence, a supply of embryos becomes an obligatory 2003). pas- point for hES cell research. sage The need for spare embryos establishes an institutional link and social interaction between the in vitro fertilization (IVF) clinic and the stem cell laboratory. These connections between science and medicine, research and therapy have been called the IVF–stem cell interface (Franklin, 2006). With stem cell research as a possible application of embryos, embryos gain a double reproductive value (Franklin, 2006: 72–73), not only valuable as potential child but also as a source for regenerative medicine. a Hence, in the fertility clinic are not only seen as a means for satisfying embryos the of having children for infertile couples but also as a potential object goal of donation to hES cell research. When clinicians in the fertility clinic ask couples in treatment to donate embryos, they introduce a question that is therapeutically irrelevant in the fertility context and addresses the couple infertile patients but as citizens concerned with the health of not as future As we shall see, the interests of clinic and research lab do patients. not always coincide and consequently the clinician has to balance clinical objectives with those of research. present study belongs to an emerging field within the social The sciences that explores the social and political conditions of stem cell research 2002; Hogle, 2003; Sperling, 2004; Franklin, 2005; Brown et (Waldby, al., 2006; Franklin, 2006; Parry, 2006; Prainsack, 2006; Scully & Rehmann- Wainwright et al., 2006; Waldby & Mitchell 2006). In Sutter, 2006; this we are concerned with what happens as the IVF clinic engages paper in research collaboration with a hES cell lab in Denmark. Only recently has issue of procuring embryos for research been an object for social scienthe tists, very few of whom (Thompson, 2005; Robert 2007) have conducted ethnographic studies to investigate the practices of donation and the atti- of clinicians and researchers towards those practices (Thompson, tudes 2005; Roberts, 2007). Based on such ethnographic fieldwork in the major fertility clinic and among stem cell researchers in Denmark, we Danish ask questions: how are embryos negotiated as objects of exchange two among clinicians and researchers in the IVF clinic, and how do clinicians and researchers in the IVF clinic handle the potential conflict between caring for patients and delivering embryos for stem cell research?

Spare Embr Landscapes

yos

and

Moral

In investigating how embryos are negotiated in the IVF clinic, we approachthe processes through which hES cell research is made possible some of in Denmark. We consider how clinicians recognize, assign meaning to and off spare embryos from other embryos. We thereby provide an mark empir- grounded analysis of the processes through which both the ically biological meaning of spare embryos are negotiated at the IVF–stem and moral cell interface. Our observations of how clinicians discuss the destinies of embryos and our interviews with them about their considerations when
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asking couples about donation have made us aware of the moral landscape of the practical engagements with hES cell research. The spatial 1 suggests metaphorlandscape, introduced by Helgason and Pálsson (1997), of moral that actors conduct transactions within a space in which notions of rightwrong obstruct or open up possible pathways. The topograph of and such landscapes is continuously reshaped in the course of those moral transactions (Helgason & Pálsson, 1997). The concept of moral landscape draws attention to the insight that to live within a moral horizon is to constitute human agency (Taylor, 1989; Helgason & Pálsson, 1997: 462). We describe how clinicians practise moral pathfinding when they get access to embryos and classify them as spare. We also discuss how moral pathways are constituted at the IVF–stem cell interface through practical organizational relations, regulatory frameworks, different notions of responsibility and techno-scientific objects. By emphasizing shifting relationships bet- human and non-human actors positioned in this interface, we seek ween to explore the networks of relations through which a moral landscape is shaped and the spare embryo as a biomedical entity emerges. By following the classification practices and reflections of clinicians and exploring the changing relations between the different components of the IVF–stem cell interface, we examine the ‘phase of emergence’ (Jasanoff, 2004: 278–79) in which clinicians and laboratory researchers explore different moral path- before they stabilize. As we shall see, the topography of the ways landscape certain pathways for action appear blocked while others open changes, as up and take shape. In the process, new notions about which embryos canconsidered as spare emerge. be

Embryo Sources
When we planned our research, we were particularly interested in how the question of donation was presented to couples having fertility treatment and the couples made decisions about donation. At the time, we took how the existence of spare embryos to be a more or less clinical or biological fact: they were embryos that were not to be used in fertility treatment. This understanding of spare embryos reflected the public debate about hES cell research preceding the passage of the Act. This debate was characterized by positions. One position considered it wrong to transform embryos, two con- as potential human lives, into cell lines and ultimately tissues ceived for regenerative medicine. Accordingly, embryos were ends in themselves, not means, in the development of medicine. This ethical assumption entailed embryos should not be used in research and therapy, not that spare even the embryo was considered unsuitable for transplantation. The when other position saw the spare embryo as an unproblematic biological resource that, used in stem cell research, might bring about revolutionary when therapies. positions took the existence of spare embryos for fertility Yet, both treatment as a biological fact and considered the donation procedure the starting point cell research, whether considered moral or immoral. During the of hES parliamentary debate, this view was directly expressed by one wellknown
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politician from a major left-wing party, Margrethe Auken, who proclaimed embryos actually exist’ (Auken, 2002). From the positions that ‘spare that emerged in the public debate, the issue to be addressed was not how to clas- and produce spare embryos but whether it was possible and sify morally acceptable to establish a relationship between the given stock of spare embryos and the stem cell lab. Unlike, for example, in Switzerland (Scully & Rehmann-Sutter, 2006), in Denmark there was to our knowledge no further discussion of what qualified an embryo to be categorized as spare. While ‘spare embryo’ was a new term to most Danes when it was introduced in public discussions in connection with the Fertility Act in 2003, the had been mentioned previously in three political–legal documents in term 2 Here the context of regulation of fertility treatment and research in Denmark. spare embryos were referred to as ‘embryos that are not transferred to the patient’, therefore representing a research resource contingent upon the informed consent of the patient (Hartlev, 2007). The 2003 Act that legalized research in Denmark echoed this definition of spare embryos as hES cell hav- been ‘originally created for IVF but no longer to be used in ing connection with fertility 3 However, neither of the three earlier documents treatment’. 2003 specified reasons for not using embryos in fertility nor the Act of treatment. For example, they did not comment on whether embryos would be ‘spare’ of bad quality or simply because they were because supernumerary. Danish law did not target specific individual embryos as Consequently, spare, it define donation procedures. Rather, it opened up a space of possinor did bility for classifying embryos as spare and developing donation procedures. By legalizing hES cell research on spare embryos only, the Fertility Act rejects two other kinds of embryo sources: embryos donated from fertile who are not undergoing IVF treatment and embryos women created CNT. In this way the political–legal process conveys a hierarchy through of embryo sources according to which the most acceptable source of embryos for research are those that otherwise would be discarded and gone to waste, embryos that according to the political rhetoric ‘already exist’. namely The acceptable embryo sources are those that are deliberately least being as research tools. created

Embryos in the Fertility Clinic and the hES Cell Lab Denmark in
Following the legalization of embryo donation to hES cell research in Denmark, we conducted ethnographic fieldwork in the Fertility Clinic at Copenhagen University Hospital over a 5-month period in the the autumn Our fieldwork sought to investigate the clinical encounter of 2004. with cell research and included among other activities: observations of stem laboratory work and informal discussions with laboratory technicians; partici- in staff meetings; and in-depth interviews with the two pation clinicians for asking couples about donation, one of them the chief responsible clini- the other a senior physician. In addition we interviewed three cian, stemresearchers from different laboratories in the Copenhagen area. cell

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Research being an important part of professional practice in the University Hospital, the Fertility Clinic has been active in embryo research back to the first embryo research protocols of the 1980s; since reaching then participated in a range of research projects on reproductive medicine it has with the Laboratory of Reproductive Biology, which is based in a neighbouring department of the hospital. This laboratory has been responsible for research on embryos in the University Hospital since the mid-1980s. Since when egg donation was legalized, the clinic and the lab have 1994, handled and unfertilized eggs originating from IVF treatment and fertilized gained experience in evaluating their quality and usefulness for reproductive pur- When the use of spare embryos for hES cell research was made poses. legal in 2003, the two institutions collaboratively launched a protocol to 4 The protocol was designed to establish lines (Andersen & Andersen, hES cell 2003). with the requirements of the newly formed British Stem Cell comply Bank important research goal was to bank future cell lines in this and an bank. the research protocol positioned itself within the network of Hence, the international hES cell research and the specific standardization processes the bank. In the national as well as the international context defined by the protocol illustrates how the category of the spare embryo connects the clin-realm of IVF and the scientific world of hES cell research engaged ical in making tissue into a certain kind of exchange object. After following the different activities related to the procurement and classification of embryos in the Fertility Clinic, we gradually realized that embryos could by no means be considered a fixed biological spare fact. were not straightforward biological objects to which ethical They questions were attached after the fact; rather a number of negotiations and an amount of reconceptualization work took place before certain embryos were classified as possible objects of donation. This led us to realize the importance of clinical decisions taking place before the couples in treatment were asked about donation. Fertility Clinic, the possibility of asking couples about At the embryo donation is an issue every morning when laboratory technicians examine the available cultured 5 to be considered for implantation in the embryo for embryo transfer between 10.00 and 12.00 hours. women scheduled When assessing the number and quality of the embryos, these technicians consider some of them may be classified as spare. There are a number whether of possible trajectories for an embryo depending on its classification. Some embryos are considered worthy of implantation, but when more than the normal one or two has been harvested, some embryos may be frozen or con- ‘spare’. These spare embryos leave the ‘pregnancy trail’ (Cussins, sidered 1996) and become possible objects of donation ready to enter the ‘research trail’ (Parry, 2006). 6 In such cases, the clinician in charge will ask the couple in question about embryo donation to research during the clinical dia- that follows every embryo transfer. In what follows we first logue comment on the social life of embryos in the Fertility Clinic, before looking more into the processes through which some embryos come to be closely consid- and thereby defined as possible objects for donation. ered spare

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In the Fertility Clinic, embryos are primarily aimed at pregnancy. Consequently, there is a strong metonymic connection between embryos and children. When observing egg aspirations, we noticed how clinicians, staff and patients expressed great excitement when the laboratory laboratory technician counted the number of eggs and described their character and appearance. The same excited anticipation occurred 2 days later dur- embryo transfer. The greater the number of ‘good looking’ ing embryos, the chance of establishing a pregnancy and thus realizing the greater the for children. This strong metonymic relation between embryos hope and children was also expressed when a laboratory technician showed us the freezer in which embryos are stored. Opening the lid of the freezer she proudly said to us, ‘here we keep all our children’. But while the clinical evaluations consider embryos a step on the way to children, and conceive of them as embedded in kinship relations, the alter- understanding of embryos as technical objects is also familiar to native both and patients. First, the embryo is ‘created’ in a network of staff laboratory is thus a technical object that is ‘at home’ in the lab where it relations and is developed, looked after, cared for and stored. Second, research on embryos that aims to improve fertility research has been allowed in Denmark since the mid-1990s and has been undertaken at a number of public and private labs, including the Laboratory of Reproductive Biology at the Copenhagen University Hospital. Seen in this light, donation of embryos for research is a ell-known phenomenon, as the w spare embryos conveys in term the political–legal documents mentioned above. Yet, while donation of embryos cell research is continuous, with well-established forms of for hES embryonicit is also different: with hES cell research, the donated research, embryothe clinical context and is considered a resource of regenerative leaves med- It is ascribed a new destiny, that is, potential therapy for future icine. citizens. Hence, recalling the concepts of biographical lifeand biological lifeintroduced by Catherine Waldby (2002: 313), we might say that embryo donation recon- an understanding of the embryo as the beginning of a particular figures biog- life and re-presents the embryo as a biological life whose vitality raphical cantransformed into a cell line that may continue its life in the lab, and be even- after being transformed into ‘medicine’, in another body. As tually, Sarah Franklin (2006) observes, the embryo acquires a new ambivalence as its double reproductive value makes it useful in more than one place: not only in the but also in the hES cell clinic lab. Observing daily routines in the fertility clinic also made us aware of yet another destiny of the embryo: the dustbin. When embryos are considered unworthy of implantation, they are not always classified as objects for donation. Many are thrown out. Thus clinicians’ classification system embryos to at least five different fates: they may be consigns transferred a woman’s uterus in the hope that they will become the back into starting a biographical life; they may be frozen in hope of being used point of in either fertility treatment or in lab work; they may be thrown out; they may be donated to fertility research; or they may be donated to hES cell research and engineered in the laboratory in the hope that they will end up
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as regenerative medicine providing new life for other citizens in the future. The choice between these different futures for the embryo is part of the clinical negotiations through which embryos are classified. As daily we see next, the telos of the embryo is often open for clinical shall (and patient) decisionmaking.

Negotiating Futures

Embryonic

During interviews, the clinicians stated that asking couples to donate embryos for research was normally a straightforward matter. Yet, they also expressed with the situation. This discomfort seemed related to the discomfort introduc-research matters in an otherwise purely therapeutical tion of context. laboratory technicians and clinicians classified the cultured As embryos, some were described as ‘good-looking’ or even ‘beautiful’ and considered well suited for implantation. Others were described as ‘looking ugly in the microscope’ or simply as ‘not good-looking’, which meant that they mighta chromosome disorder or a similarly serious condition. The classificahave tion of embryos is based on a number of more or less strict parameters. These include the uniformity and symmetry of the blastomeres, the degree of fragmentation, and the presence of multinucleation. ‘Poor embryos’ are viewed as having a low chance of producing a successful pregnancy when transferred to the woman’s uterus. By naming embryos ‘ugly’, ‘not so nice’, ‘good-looking’ or ‘beautiful’, clinicians classified the possible future of harvested embryos and negotiated their destinies. The naming and classification of the embryos was an interpretive activity in which laboratory discussed among themselves the appearance and quality of assistants the embryos in relation to a particular couple’s stock of embryos. common practice to define ugly-looking embryos as spare It was and hence as possible objects for donation. This definition was in harmony with clinicians’ therapeutic goals. The head of the clinic (Y) said: ‘We have the policy of using the embryos which we would otherwise have destroyed’, ‘we will not reduce our patients’ chances … we want to adding that bene- … and give them the optimal chance of getting pregnant … fit them ’. Accordingly, this clinician considered it rather unproblematic to ask cou- about donating therapeutically useless embryos, since the choice ples was between dustbin and research. Couples were thus asked to the waste into a valuable resource for transform the research trajectory. As the senior physician (X) added, this meant that the couples were ‘not to make a real sacrifice’ – a view that echoes an argument in the public debate to the effect that spare embryos are useless for producing children. Despite the association of spare embryos with waste, our interviews indicated that clinicians often classified embryos as ‘spare’ not only on the of the embryo’s ‘ugly’ appearance and its definition as waste, but basis also because of organizational issues , such as the clinic’s time schedule or lab’s situation. On a busy day, thethe clinic would sometimes choose not to time to ask couples to donate, and the laboratory was not always take ready to receive fresh embryos. On any given day, was it possible for the clinic to
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get hold of the lab guys and ask if they needed any embryos that day? One clinician told us about a time when the lab people were away for a weeklong conference. During that time, they did not ask couples to donate any embryos, because they could not be processed in the lab that fresh week.also would happen when a lab technician was sick or on This holiday. our fieldwork progressed, it seemed as though the rationality As of declaring an embryo as spare because of a lack of fertility potential reached its limits at the IVF–stem cell interface. In an interview, the chief lab engi- (Z) at the Laboratory of Reproductive Biology expressed regret neer that embryos he received were too few in number and too poor in the quality. He described the growing need for good embryos in the lab as a ‘bottle- his kind of research. Being at the receiving end, he depicted neck’ for him- as passively waiting for embryos to be delivered from the fertility self clinic. Speaking of the quality of the embryos with which he had to work, he said: ‘I receive so few embryos that I have to accept what I get. Then I only hope blastocyst to give me the chance to go on working.’ He had not for a yet produced a cell line out of the approximately 100 embryos he had received past year. While he was very pleased with his relationship during the with the clinic and fully understood their difficulties, he had his own way of seeking to improve deliveries: ‘If I exaggerate a bit and say “come on”, then deliver embryos for a couple of days and then things return to they normal.’ clinicians were also unhappy about their inability to deliver The highquality embryos to the lab and wanted to do more to live up to their part ‘deal’ . The head of the clinic (Y) explained it in the following of the way:
We felt fine about using the embryos which would otherwise be thrown something sensible and useful which could be of benefit someout for where else. That was not difficult, but the next step [to satisfy the lab with good-looking embryos] is more difficult, and there might be more than one viewpoint here. … It is a process … and the truth is that a number of embryos we have delivered have not given the expected results; the some stop functioning after a couple of days, and we know for sure that of them the more handsome and regularly divided embryos we deliver, the greater the chance that they will be useful in the lab. A lot of the embryos we have delivered are third or second class.

At staff meetings, clinicians discussed how best to meet the researchers’ more ‘good-looking’ embryos, and asked as if this would imply demands for that ‘real sacrifices’ had to be made by the infertile couples. They also discussed if the clinic should raise the possibility of embryo donation to cou- with many ‘good-looking’ embryos, and one day the head of the ples clinic the expression ‘to move in on the young, rich and beautiful’. coined This referred at once to the most promising stock embryos (the beautiful of the most ‘well-off’ ones as they have the greatest fertility potential) ones are and to couples (the couples, who are young and rich in beautiful the the best chances of pregnancy and often do not use all of their embryos have embryos a pregnancy). Moving in on ‘the young, rich and beautiful’ to obtain thus characterized both beautiful embryos and their clinical implications. In different situations – at staff meetings and in conversations with us – number of the
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embryos was introduced as a possible criterion for classifying some of them as spare. These were embryos that were ‘surplus to requirement’ et al., 2006) and thus eligible for donation, but which also (Wainwright had clinical potential. As expressed by the head of department (Y):
If the lab cannot work with embryos that are not of high quality, then we to do things differently [in the clinic]. My personal opinion is that need it fully legal to ask someone with handsome, regular embryos … if you is have a surplus of handsome regular embryos which may be frozen, then total chance of pregnancy is around 80%. It is fully legal to ask your the with an extra, excellent, superior prognosis. … I feel fine about askgroup ing them if they will donate some of their embryos. Also if they are amongmost handsome the ones.

Yet, even when couples had a large number of good-looking embryos, the social–psychological situation of the couple in treatment played an impor- in the negotiations over the ‘spareness’ of their embryos. The tant role sen-physician (X) explained it in the following ior way:
I find it easiest to ask about donation if the couple is young and they have good-looking embryos. Such couples usually have a good chance many of pregnancy. … Yet [the] last time it was suggested that such a couple be asked, I argued that this particular woman was not strong should and I did not wish to burden her with yet another thing. I did not find that it right to make her consider embryo donation.

By not classifying any of this couple’s embryos as spare, the clinicianher commitment to the therapeutic values of the clinic. Still stresses her moral reasoning also conveys her strong commitment to hES cell research: the resources [embryos] and we feel obliged to help [the lab] ‘We hold but is no direct benefit for us. We are engaged in this research and there thus needs to have made the decision to participate, decide if it’s worth one it.’ head of department (Y) chief supplemented her The view:
The only connection is that we have the fertilized divided egg – otherwiseno connection … we [our hospital department] do not reap we have the potential benefit of hES cell therapies, we don’t have the patients who will ultimately need these therapies more than many other [hospital depart- – rather ments] less.

The problematic issue for these clinicians was not – as in public ethical over hES cell research – the destruction of the embryo as debates potential biographical life. The problematic issue to them was to strike the right balance carrying out a successful fertility treatment on the one hand and between contributing to research and science on the other. Hence the double reproductive value of embryos established a double responsibility: responsibility for patientsas responsibility for research. The classification of embryos as spare as well was fraught with tension between the clinicians’ obligation to treat infertile and their eagerness to contribute to the development of patients regenerative clinicians sought to work out a moral pathway that medicine. The would
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strike the right balance between these dual demands. Their deliberationsbalance can be described as a matter of ‘practical about this reasoning’ 1998), exploring what would be the right action in a certain (Mattingly, situ- This reasoning process arises from the practical and personal experience ation. of being engaged in clinical work while also being involved in research. Consequently, the embryos are constituted as highly complex entities with multiple futures. Altogether, the interactions between and considerations of staff spell out the point that spare embryos accessible for hES cell the research a fixed ontological entity, but an emergent and negotiable are not classification constituted in relation to a couple’s situation – the number of their embryos, their age, their social–psychological situation – and the situation in lab. If the lab needs embryos, the clinicians not only demonstrate a the greater to ask couples to donate, they also seek to practise expanded readiness notions of spareness and consequently more embryos become ‘spare’. While the general debate about embryo donation in Denmark leaves the impression that donation begins with the request to the couple, our observations tell a different story: a number of clinical actions and estima- made that construct particular embryos as ‘spare’ before tions are couples are approached. Thus the first step is a classification process through which embryos are evaluated with the microscope, and such evaluations involve of responsibility towards patients and research, estimates of notions the emotional strength of patients, and organizational relations between clinic and laboratory. Put differently, two embryos that from a biological point of view appear identical may be classified differently depending on how the clinician understands her professional responsibilities with specific patients in the context of the lab situation. When the clinicians assess the destinies of embryos, they manoeuvre in a social space shaped by the sometimes rationalities associated with caring for patients and conflicting contributing Hence, the ethics of donation is not simply a question of to research. howhES cell lab acquires a stock of spare embryos. It also involves a the social through which moral pathways are negotiated and embryos process are classified as ‘spare’ objects available for exchange. In a global – primarily American – context, the ethics of handling spare embryos have often been considered an issue of ‘life ethics’ (Roberts, 2007), the life of the embryo has to be rescued at any price and ‘adoptive where par- willing to bring them to term found through fundamentalist Christian ents’ initiatives such as ™ Embryo Adoptions Snowflakes (<www.nightlight.org/ is now being snowflakeadoption>). The universality of this view challenged from several sides. Writing on the Ecuadorian experience, Roberts (2007) shows ‘ethics of kin’ considers the destruction of spare embryos more how an acceptable than circulating them between genetically unrelated families. Compared the Danish clinicians seem to practise a ‘therapeutical ethics’ that with this, puts interests of the patient (i.e. the IVF couple) before that of the the embryo.

Moral Pathfinding

During our fieldwork, clinicians did not find it easy to numbers as a criuse for classifying embryos as spare, because spareness conflicts with terion the
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clinical ideal of producing no more embryos than is needed for treatment. The number of eggs produced in a cycle is not solely a result of 7 Stimulation and extraction natural but one of clinical decision-making. forces, of eggs involves some risk, and so ideally no more eggs should be 8 From the point of view of extracted than needed for a successful pregnancy. optimal solution is to implant only one or two eggs, clinicians, the which aspirating and fertilizing very few eggs. Hence, while the requires clinicians agree that asking couples to donate ‘good-looking’ embryos tentatively for research is the right thing to do, this practice conflicts with their ideal of using such embryos for treatment. The senior physician (X) explained her discomfort with this situation by referring to the viewpoints of her Belgian colleagues: ‘In Belgium they consider that to take embryos from couples in fertility treatment is like stealing candy from children.’ With this analogy, embryos to a treasure or limited resource that is the property she likens of couples in treatment, and her mention of ‘stealing’ implies a violation of their property right. n such negotiations, one particular question stands out: When is I it morally acceptable to ask a couple in treatment if they want to donate an embryo for research? The chief clinician (Y) put it this way: ‘We have debated where the cutoff point is – is it eight or ten [embryos]? We have had a rule of thumb say- that if the patient didn’t have at least ten to herself then we ing wouldn’t the head of the clinic and summed these difficult issues up as ask,’ says ‘a classical discussion of decency … we find it decent to ask only if they [the embryos] are to be discarded or if the patient is in an exceptionally favourable situation’. The criterion for knowing whether the right decision has been made was clearly expressed:
Does one feel comfortable afterwards? One would feel very uncomfortable if one had extracted four eggs and the woman donated three for research and the fourth which was left didn’t divide. And one has to talk to her one- and explain that the remaining egg didn’t divide. This is not self bearable.

Aside from the retrospective ‘criterion’ – ‘how does one feel afterwards’ – this clinician introduces an additional numerical criterion – a ‘rule of thumb’ – for counting embryos as surplus. This numerical reckoning liter-implies a moral economy of embryo production: above a certain ally number, embryos can be counted as surplus. The clinician gives the example of insufficient number (four), and it seems that he has a rough idea of an how embryos is enough, even though this number depends on the many situa- the couple and the couple’s history. Caught between the needs tion of of patients to secure an ample supply for reproductive purposes and the the pressures from research to extract more embryos in order to get the number above eight or ten, the clinicians struggle to strike the right balance in moral economy. If five or eight is the right number for therapeutic this pur- in most cases, and ten the cut-off point for defining a surplus, poses thenobvious next step would be to extract more embryos than ten. In the conversations with us the clinicians articulate this idea of stimulating women
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hormonally in order to produce more eggs than therapeutically necessary for successful IVF, yet they immediately abandon this line of thinking. way, expressing a ‘philosophy of the limit’ (Rapp, 1999: 308) In this – an idea of what is and what is not acceptable – the head of departmentthe danger of letting research norms spill over into describes therapeutic practice. Asked whether he felt a conflict between his role as clinician and as researcher he answered, ‘Yes, I do see a slight conflict in a clinic like this one. I’m responsible for the clinic, and as a university hospital we have a uty to develop and do research and, in a way, the conflict comes d about because this is the overall purpose.’ In their study of how ethical reasoning occurs among researchers in a British stem cell lab, Wainwright et al. (2006) introduce the term ‘ethical boundary work’, a term for how scientists place themselves in an ‘ethical space’ that requires them to make moral judgements. The clinicians we studied engaged in ‘ethical boundary work’ talking about ‘stealing candy from children’, ‘feeling when uncomfortablerejecting the possibility of intensifying hormonal afterwards’, stimulation and thus expressing a philosophy of limits. Yet, no well-defined ethical emerges out of the ethical boundary work in the Fertility space Clinic. when describing the different interests at stake in the Rather, production and classification of embryos the clinicians seek more firm moral footing. Their double responsibilities require them to strike a balance between the professional duty of caring for patients and the professional duty of contributing to research by providing the necessary raw material. In their conversations with us, they offered no definite solutions. Although the criterion of ten good embryos was articulated as the cut-off point, ambiguity, doubtguilt come into play because judgements about quality and and sufficient number vary with assessments of the couple’s age and clinical history. In addition we have encountered the view among clinical staff that all embryos couple’s property and of potential value to were the them. the discomfort that clinicians expressed did not make them Yet sidercongiving up their engagement in hES cell research. They described as fascinated with such research and viewed themselves themselves as important actors in this promising research field, as they were the only ones could provide access to embryos. We suggest that the great hopes who asso- with regenerative medicine contributed to the clinicians’ ciated commit- hES cell research: and so, as we shall see in the next section, ment to rathergiving up their engagement in hES cell research, they sought than alternative sources for embryos by way of classifying spare embryos for donation to research. New moral pathways are formed in these processes.

A Changed Landscape

Moral

The clinicians’ way of inhabiting the research and clinical domains involvedfor an acceptable road through a complex moral landscape. groping Identifying with research needs, they considered whether they should ‘move the young, rich and beautiful’. Identifying with their patients’ in on needs, they refer to their Belgian colleagues and describe the very issue of donation
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as an unethical appropriation of the patients’ ‘treasure’. During our field- such conflicts motivated them to look for other sources of work, embryos compare donations for stem cell research with another and to possible source being discussed in Denmark at the time, namely donations from 9 In fer- women to couples in fertility tile an interview the treatment. senior physician (X) exclaimed:
A lot of these problems could be solved if well women, healthy and all, were informed about the extraction procedure and had a low dose of stimulation, and were allowed to donate eggs [to stem cell research] … people may donate kidneys, why the hell not this.

This clinician suggests that donations from what she considers a less vulnerable population, fertile women, are a way to solve the clinic’s problem with pressuring patients to donate ‘spare’ embryos. By linking the need for embryos for research with the acceptability of asking fertile women good to donate eggs to infertile couples, clinicians in the IVF clinic can be seen to as moral pioneers (Rapp, 1999: 306) breaking into an unknown act terri-1 They propose a new moral pathway: obtaining good embryos tory. 0 from fertile donors voluntarily created for research is more acceptable than tak- good embryos from IVF treatment. In terms of the candying stealing she says: ‘Do not steal candy from kids, but take it from metaphor, adults. they will have money to buy something At least new.’ tem cell researchers were also concerned about the practice of makS ing couples in treatment donate ‘good-looking’ embryos, and they also out alternative moral pathways. At a recent hearing, a stem tried cell researcher spoke of the controversial use of CNT as a method to 1 obtain high-quality The chief lab engineer at the Laboratory 1 embryos. Reproductive Biology (Z)of described the use of the preimplantation genetic diagnosis (PGD) on IVF embryos as a possible source of embryonic material that would circumvent ethical concerns connected with cre- embryos ‘solely for research’. Also the embryo would not ating be destroyed but used for its original purpose of creating a biographical life. In his words:
Using the PGD technique we could take a few cells from the embryos to used in fertility treatment [and create stem cell lines from the be ‘few If that embryo [transferred back into the woman’s uterus] cells’]. became and if we succeeded making a cell line [from the few cells] a child that would have the perfect reservoir of spare parts because then it would child have precisely its own cells. And those cells would be there for the child could use them for therapeutic purposes if the parents were ready and we for this.

Such efforts to circumvent legal and ethical restrictions are evident in many besides Denmark. In the USA, a similar procedure to this one places has mentioned as a possible solution to restrictions on stem cell been research, successfully quelling opponents (Wade, 2006). Another without possibility that the chief lab engineer envisioned was to use discarded PGD embryos.
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By this method, embryos at day 3 (the eight-cell stage) are genetically tested for serious genetic disease and the embryos that test positive are discarded. While discarded PGD embryos are a common source of stem cell material in, for example, the UK, they are not used as a source for the production of cell lines in Denmark. The chief lab engineer considered discarded stem PGD embryos as a possible legal source of spare embryos, but the clinical staff were not happy with the idea, because it would burden couples under- PGD with yet another decision. From their point of view, PGD going cou- are already burdened with information and informed consent ples forms, taking ‘spare’ embryos from them would represent an even and so more unethical action than taking them from ordinary IVF patients. chief lab engineer (Z) also contributed a distinctive view to the The rent curdefinition of spare embryos: ‘when eggs have the potential to be fertil- think they belong to the woman … I don’t think an egg is spare ized I before the woman has had her baby.’ And he continues: ‘As long as it has a fertility potential then I think the woman should have it.’ While illustrating the ambiguity of turning embryos with fertility potential into spare embryos, his statement also indicates how alternative solutions are connected with, or even presuppose, different ways of problematizing the ethical relationship between embryos from fertility treatment and material for hES cell research. alternative pathways through the moral landscape arise from These contestation over what counts as the most robust embryo source in terms of both availability and ethics. Following the change in the Danish Fertility Act in 2003, clinicians tended to favour a position in which scientists take over only ‘waste’ appears in the clinic, a position also shared by hES after cell researchers in a British study (Wainwright et al., 2006). Yet, because laboratory researchers view embryos with no biographical prospects as useless, clinicians turn to ‘good’ embryos and now categorize them as surplus for therapeutic purposes. In the clinic this solution reinforces the conflict clinical and research responsibilities, and both clinicians between and researchers come to question donations from IVF patients as the most ethical source of embryos for research. Seeking out a way to obtain embryos for research without transgressing ethical lines, they suggest that either cells from embryos, embryos created through CNT, or ‘good’ embryos from fertile are morally preferable. 12 Their moral pathfinding reverses the hierardonors chy of embryo sources established in the Fertility Act. What the Fertility Act implicitly treated as the least acceptable source of embryos, that is, embryos women deliberately created as research tool, is now articulated as from fertile an attractive solution to the unmet demand for research embryos.

Conclusion
As we have seen, the moral landscape of the IVF–stem cell interface is continually recreated in relation to organizational relations, research pro- techno-scientific objects, clinical classifications and notions of tocols, professional responsibility. Our study illuminates the central role of the in the innovation process (Keating & Cambrosio, 2003: 327), clinic as
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well as the central role of the innovation process in clinical decision-If we consider this intimate link between clinic and lab, the making. case conveys how organizational continuity may become a vehicle for trans- the moral landscape of embryo transactions. Both hospital forming units contributed to hES cell research when they developed a new research and gained the necessary approvals from the scientific ethical protocol committee. This research protocol constituted the clinic as a crucial actor cell research, with its great hopes and high expectations, and in hES com- the clinic to deliver spare embryos to the lab. Yet, continuing mitted what have always done, participating in research and taking care of they fertil-treatment, clinicians experienced a conflict between ity researchers’‘good-looking’ embryos and their own responsibility for demand for treatment. The way clinicians handled the conflict made it clear that their primary commitment remained towards the patients. Faced with the demands of research, however, they tried out new pathways and rearranged boundaries, in a search for acceptable alternatives. Their linguistic and clinical practices should not be seen simply as rationaliza-as truly innovative for both scientific research and tions, but ethical and practices. In other words, their efforts forge new pathways norms to circumvent the conflict and co-produce a changed moral landscape and notions of what constitutes the raw material of hES cell new research. together, the ongoing fact-making of the spare embryo in the All fertility clinic renders visible the situatedness of moral reasoning in specific practices. Employing de Certeau’s (1984: 115–30) distinction between ‘map’ and ‘itin- we might say that traditional medical literature on erary’, maps different ethics principles and thereby presents an overview of different viewpoints and their relation to each other. Contrary to this approach, our ‘bottom-up’ approach reasoning in clinical decision-making highlights to moral itineraries the through a landscape. That is, it reveals how clinicians and stem cell researchers continually rework paths, trace new itineraries and in so doing the landscape. Depicting the turns taken and the transgressions recreate made in specific relationships as we have done here demonstrates that clinicians and cell researchers do not just propel themselves from one location stem to another as if following a route on a map. Rather, they move in a landscape thatshaped and reshaped concomitantly with and by their is activities. In addition to providing us with access to a moral landscape traversed by itineraries, the paper also conveys how those itineraries are integral to making of spare embryos. In terms of ‘built-in ethics’ (Franklin, the 2003), this implies that hES cell research not only constructs material embryos,builds relationships to patients and colleagues. In other words, but also the organizational relations, professional responsibilities and moral pathways that make up the moral landscape of the IVF–stem cell interface are co-produced along with the spare embryo itself.

Notes
We wish to thank the Danish Agency of Science, Technology and Innovation for financing (24-03-0219). We are very grateful to the clinicians and stem cell researchers our research

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who allowed us into their clinics and laboratories and took time to give interviews and have conversations with us. We thank them for constructive comments on this work. Our thanks also go to Klaus Hoeyer for very useful and focused suggestions on an earlier draft of this work and to four anonymous reviewers for many good comments. 1. Helgasson & Pálsson (1997) use the concept of moral landscape to study the social dynamics of the discursive space in which transactions are negotiated, using the case of commoditization of fishing rights in Iceland as an example. Their attention the to topography and pathways is also analytically stimulating when it comes to understanding the ambiguities of the moral environment in which transactions of body material take place. 2. The notion of the spare embryo first appeared in the Danish equivalent to the Warnock Ministry of Internal Affairs in 1984. The concept was later mentioned in report the treatment of the bill concerning the establishment of the Ethical Council in 1986 and in comments to this bill in 1991 (Hartlev, 2007). 3. Besides the clinic and the lab at the university hospital, the fertility clinic at another publicly financed hospital participated in the project. The protocol mentions three possible sources of embryos: frozen embryos no longer to be used for reproductive purposes; fresh embryos not needed for reproduction; and unfertilized eggs not needed for reproduction. Our analysis primarily deals with the second category of embryos as donations of frozen embryos have not been part of our fieldwork. 4. The routine at the clinic is to do early (day 2 or day 3) embryo transfers, often to transfer a single high quality embryo and to rely on the cryopreservation programme. Due to this procedure, one-third of all transfers are with thawed embryos. 5. In the clinic, embryos that have been frozen earlier but now reached their expiry date also being considered for donation (see Bangsbøll et al., 2004), although the quality are of fresh embryos is considered the best. 6. This point was already made by Søren Holm (1993). 7. While embryos can be frozen, eggs cannot be with current technology. we submitted this paper, donation of unfertilized eggs from fertile women 8. At the time to couples in fertility treatment had been legalized in Denmark. 9. Thanks to Nikolas Rose for suggesting the image of moral pioneers, originating in Rayna Rapp’s work. Thanks to Martin Bauer for suggesting that we explore the landscape metaphor. 10. Mustapha Kassem at an internal hearing of Danish Ethical Council 30 November 2006, available at <www.etiskraad.dk>. 11. These different ways of obtaining embryos of good quality for stem cell research imply correspondingly different ways of imagining and organizing regenerative medicine. The to use embryonic cells processed with the PGD technique suggested by the head idea of lab represents an individualistic approach to the development of the regenerative which single individuals bank their own stem cells. In contrast, the medicine in solution of donations from fertile women continues the current communitarian idea of developing a great stock of different cell lines that may work as a bank for the whole community as such. Hence, different notions of the spare embryo relate to and define different visions of organizing regenerative medicine and imagining the relationshipthe individual and the between collective. 12. See Ministry of Internal Affairs (2003).

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Mette N. is an anthropologist and assistant professor in the Svendsen of Health Services Research, Institute of Public Department Health, University of Copenhagen. Her main research interests concern the organization and experiences of biotechnology in public healthcare. She studied the social implications of cancer genetics counselling and has testing in Denmark and is currently working on a research project about the coordination of patient participation in pharmacogenomic research. Address Department of Health Services Research, Institute of : Public Health, University of Copenhagen, 1014 Copenhagen K; fax: 29; email: m.n.svendsen@pubhealth.ku.dk +45 35 32 76

Lene is a historian and professor in the Department of Health Koch Services Research, Institute of Public Health, University of Copenhagen. Her research interests concern the history of genetic and main reproductive She has studied the emergence of the IVF method in technologies. Denmark 1991) and the development of eugenic legislation and the (PhD thesis, practice of compulsory sterilization in Denmark (DPhil thesis, 2000). From 1994–2000 she was a member of the Danish Ethical Council. Address Department of Health Services Research, Institute of : Public Health, University of Copenhagen, 1014 Copenhagen K; fax: 29; email: koch@pubhealth.ku.dk

+45 35 32 76

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