Recently, a California company has begun creating and selling embryos, which poses a range of ethical questions that have received little scholarly attention. Other clinics may now consider doing the same. Strikingly, this new market has received attention in the popular media, but relatively little in the academic literature. In this procedure, a clinic obtains sperm from one donor, and oocytes from another, and then combines them to create embryos that the clinic itself owns, stores, and then sells. Such cryopreserved embryos can enable would-be parents who lack both sperm and eggs to have children, but several critical ethical dilemmas emerge. For egg donation, the European Union bans compensating more than relatively small amounts (ie, for time and inconvenience)–generally less than approximately US $1000–while fees in the US usually range from $5,000–10,000. But, should we now permit buying and selling embryos, too; if so, how? Some individuals and organizations may immediately oppose this technology for religious or moral reasons. Some feminists and others have viewed the sale of eggs, and presumably embryos, as commodification, arguing that such markets cheapen human life. But can these procedures be ethically permissible, depending on how and for what indicators they are performed? As outlined in the Table , several questions and challenges arise.

Cohen and Adashi recently concluded that the ethical issues involved in creating embryos for donation are essentially no different than those posed by buying and selling human sperm or eggs or donating embryos. The only clear difference, they argue, concerns legal issues of parentage.

Yet, although some of the issues are similar, others differ markedly. Neither an egg nor a sperm, by itself, can become a human being; however, an embryo certainly does, which arguably warrants special consideration. A purchased gamete contains only one-half of the future child’s DNA, whereas the embryo contains the entire genome. Moreover, creating embryos raises questions that are related to quandaries of “when life begins” and “when an individual commences.” Some individuals believe that embryos have greater moral standing than do gametes. In our pluralistic society, broader ethical debates continue over that issue that we cannot resolve here. But that debate does not need to be resolved to examine particular critical issues that arise regarding embryo sales. Even regarding similar aspects of purchasing a gamete vs an embryo, commercial transactions that involve embryos raise these dilemmas more acutely and forcefully, which should prompt us to revisit, rather than ignore these ongoing controversies in this new context.

In this article, we examine arguments pro and con and suggest ways of potentially proceeding. Should embryos be thought of as a commodity, a product that may be bartered or sold in the open marketplace, or as something different; if so, how? Questions arise concerning whether guidelines or parameters should be developed, and if so what should they be (eg, whether they should regard anonymity or potential future contact or mandated or permitted exchange of information between offspring and gamete donors; limits in the number of offspring created from each batch of procured gametes; and the final dispositions of any embryos above this arbitrary number). The World Health Organization states that cells and tissues should be donated only without payment, except for reimbursement of reasonable expenses (eg, loss of income), and without any “advertising the need for or availability of cells…with a view to offering or seeking payment…” Yet, international consensus documents are not always followed and do not constitute law; in the United States and several other countries, the advertising and purchase of gametes regularly occurs.

Physicians from a wide variety of specialties should be aware of issues related to embryo and gamete donation, because they may well be asked questions regarding these techniques and practices. In the future, patients with diseases that are associated with genetic tests may wonder whether to screen embryos or to purchase others’ gametes or embryos from nonaffected donors, instead of using their own, and may ask internists, obstetricians, pediatricians, psychiatrists, and others. Clinicians can refer such patients to assisted reproductive technology specialists; however, familiarity with the basic aspects of these issues and the complexities that are involved could aid them and their patients.

Currently, the practice of selling embryos may be relatively limited in scope, but the number of providers doing it remains wholly unknown. Even if it may not be widespread presently, it will undoubtedly become far more prevalent, as have other new assisted reproductive technologies. The unique nature of the embryo as an object for sale makes the ethical questions raised critical.

Arguably, the different possible indications for embryo donation affect the ethical considerations in each case. For couples in which both members lack gametes, the procedure may be justifiable ethically, depending on how it is performed. Yet, couples who purchase embryos to achieve offspring with particular desired nonmedical characteristics (eg, blond hair and blue eyes) pose several concerns.

Questions arise, too, concerning the rights of the unborn children about their ability to know their biologic parents. Presumably, many of these offspring will never learn that their biologic parents are not their parents. Companies that create human embryos de novo and gamete donors themselves may wish to keep donations anonymous. Currently, many sperm or egg recipients do not tell their child that he/she was conceived with the use of someone else’s egg or sperm, fearing that the child will love them less. However, research has suggested that most adults who were conceived using donor sperm want information about their donors and think it should be provided. Some offspring inadvertently find out later (eg, if a relative discloses the information or if the offspring discovers medical or legal documents) and may as a result feel disturbed, confused, mistrustful, and alienated. With a donated embryo, parents may be even more reluctant to disclose that donation occurred, because neither of them is biologically related to their offspring. Hence, with many cases of embryo donation, no contact will probably ever occur between both–not only 1–of these biologic parents and their offspring. Yet, such disclosures may be important for these individuals, who may gain knowledge that can aid their physical and psychologic health. Gamete donors may, for instance, later discover genetic cancers or other serious familial diseases that would be important and useful information to these offspring. Many predictive genetic markers are best interpreted in the context of the patient’s family medical history.

Offspring may also want to the patient’s from whom they are descended for the knowledge in and of itself – to know their “roots.” They may also reflect differently on their own identity if they know that they were created from embryos that were produced by individuals who never met and had nothing, knowingly, in common. Moreover, their biologic parents each in fact provided these gametes for money and thereby created the offspring partly for monetary self-gain, rather than love or altruism alone. Arguably, offspring have a right to know this information. One might argue that such disclosures may cause harm. But data from sperm donation suggest that the benefits of disclosures outweigh the possible risks.

Questions arise, too, concerning how much providers or agencies should charge for embryos. The American Society of Reproductive Medicine (ASRM) has stated that women who donate eggs may be compensated for their time and the risk involved. Payment, however, should not be for the eggs per se but for the service rendered and not tied to the quality of eggs. Unfortunately, many donor egg agencies and fertility clinics pay more for eggs from women with more perceived desirable pedigrees (eg, higher SAT scores) and “proven” successful past donation.

Desires of some prospective parents for specific traits in a baby (eg, height or eye/hair coloring) can prompt creation of embryos from 2 gamete donors who each have these traits. Because egg donor compensation has varied based on desired attributes, the costs of embryos may also reflect the desirability of perceived traits. Questions thus emerge of whether “bidding” for highly valued embryos should be allowed (with sale to the highest bidder, driven by market demand), and embryos deemed less desirable should be “discounted.” Wealthy prospective parents may be able to bid competitively for embryos from gamete donors who were screened more extensively for health, beauty, athleticism, intellect, or avoidance of various mutations or less desirable traits, which could then widen the gaps between the haves and the have-nots, potentially fostering inequality and injustice. Future selection for or against certain traits (eg, obesity or homosexuality) may promote misunderstandings that genes “cause” certain traits that may instead result from complex interactions of both nature and nurture.

ASRM issues guidelines, but neither systematically monitors nor enforces them, and a portion of clinicians fail to follow these recommendations. For instance, ASRM recommends that donors be >21 years old, but >40% of clinics appear to target younger women, who generally have better quality eggs but who may not have considered fully the long-term consequences of donation. Nonetheless, these guidelines serve critical roles, establishing standards of practice to which many providers appear to adhere. ASRM could consider issuing additional guidelines that the costs of embryos offered to patients should not be linked to perceived desirable qualities.

Ownership of embryos that are created without an advanced directive by patients pose dilemmas, too. What if the creating party, corporate or professional, goes bankrupt (as did the Icelandic biobanking company, Decode Genetics, resulting in ownership of all its genetic data by a British holding company)? What if one or both gamete donors change their mind and demand either access to the embryos for their own personal use or destruction of the embryos? They may have signed a contract that defines the nature of their intent at the time of donation, but is it enforceable, and if so, in perpetuity? Questions emerge if the individuals who purchased the embryos wish to resell or donate them to others or they divorce after buying, but before using the embryos.

Additionally, unbeknownst to each other, full siblings potentially could meet, get married, and procreate. Embryo banks may argue that this event is unlikely because these offspring may be born all over the country. But people move, and companies are located in particular regions from which they disproportionately obtain patients. Moreover, no guidelines limit how many embryos these programs can create and sell, and the buyers are not followed over time. Egg donor and embryo registries are desirable, but do not yet exist. Until they do, intermarriage, although not very likely, is entirely possible.

Guidelines also do not exist to limit the number of prospective parents who could buy embryos from a given pair of gamete donors. Cohen and Adashi argue that concerns about potential intermarriage among children born through embryo sales “apply equally” to children born from single gamete donors and can be handled through similar regulations and procedures. But the situations differ significantly, because offspring from the same sperm donor, but different mothers, are half siblings and share only around 25% of their DNA. Offspring from the same batch of embryos (ie, the same egg and sperm donors) would be full biological siblings and share around 50% of their DNA. The risks of recessive diseases in their offspring are thus much higher.

Several of these issues can be addressed relatively easily through guidelines from ASRM. The organization can, for instance, limit the number of purchasers of embryos from each pair of gamete donors, require that providers report the extent and details of this practice, consider requiring that the gamete donors involved agree to be contacted in the future, that prices not vary based on nonmedical traits, or that a registry be created to allow for facilitation of future such contact. These possibilities should at least be considered and discussed. Because this practice will likely spread, appropriate guidelines are critical to establish as standards of care for the benefit of the future offspring and to ensure ongoing public trust.