| INTRODUC TI ON AND BACKG ROUND
Discussions in the broader literature regarding the emerging biotechnology of in vitro gametogenesis (IVG) 1 suggest high hopes for the possibilities of the intervention; from the use of the process to facilitate access to embryos for research purposes, 2 to enabling people who currently rely on gamete donation to reproduce to have genetically related children. 3 As Smajdor writes: "The successful development of [artificial gametes] for reproductive purposes would mean that gametes could be obtained using genetic material from the prospective parents, whether or not they ever had viable gametes of their own." 4 That people who currently rely on the use of donor gametes to reproduce would be able to have genetically related children with IVG is an exciting prospect, and one which in turn raises questions regarding the future of gamete donation. This paper explores these with a focus on egg donation in particular, and asks: If IVG were safe, effective and inexpensive, when (if ever) would egg donation be ethically justifiable?
One might be inclined to wonder at this point whether there could indeed be instances where a fertility patient would still prefer to use donated eggs, even where IVG was available and cost-effective, and had been shown to be safe. This is not unthinkable, and it is an important question to ask. There is of course a practical aspect to this, for if there were no demand for egg donation then both public and private healthcare organizations would need to respond accordingly. But this possibility raises ethical questions as well, as indicated by the question above-the answer to which would of course inform whether it would be ethically acceptable to continue to pursue egg donation once IVG has reached a point where it is safe, effective 1 | 61
CARTER-WALSHAW
and cost-effective. Further, the question and corresponding discussion also provide a new context in which broader questions around both IVG and egg donation can be explored. The assumption in the literature seems to be that IVG will eliminate the need for gamete donation if it is found to be safe, effective, inexpensive and ethically acceptable. As such, there has been no consideration of whether there might in fact be demand for gamete donation to continue in parallel to provision of IVG, or to what the ethical implications of this would be in the context of egg donation in particular (given the invasiveness of the process and the risks and harms involved). Some of the reasons why people might prefer donated eggs to the use of IVG are explored in the broader literature-in particular the view that the latter intervention is "unnatural," and concerns regarding the psychosocial impact that being born through IVG might have on the resulting child. These are provided as possible criticisms of IVG more broadly, and while this will be true of their use here, the context in which they are being discussed in this paper (the ethical acceptability of providing egg donation as an alternative treatment option) is different to how they have been previously approached. This paper explores issues and concerns that might inform a recipient's reasoning in choosing to use donor eggs instead of eggs produced through IVG (even though the latter would lead to the creation of children to which the recipient would be genetically related). This section concludes with the assertion that egg donation can only be ethically justified in specific, serious cases given the (hypothetical) availability of IVG treatment, and further, that even then egg donation as we know it today could be replaced by donation through IVG techniques.
Following this, two possible replies to this conclusion-respect for patient wishes, and the loss of donor benefit-are explored.
This paper therefore considers some issues that are relevant today-the harms and risks involved in egg donation-and explores them within the context of the emerging field of IVG. Currently, if the intended mother is unable to produce her own eggs then there is no alternative method for her to have her own genetically related children 5 -in short, if eggs are needed then egg donation is the only way to acquire them. 6 However, IVG could offer an alternative:
Allowing people who cannot provide their own eggs to have eggs created from their stem cells and to have a genetically related child.
This paper in turn forms part of a broader discussion on the replacement of current biomedical interventions with emerging technologies, particularly the use of "artificial" forms of organic articles such as organs and organoids 7 (which could eliminate the need for human organ donors and aid pharmaceutical research), and of course gametes. Cases in which a woman undergoes the medical procedures related to egg harvesting with the sole intention of going on to donate those eggs will be the principal focus of this work; other kinds of egg donation, such as egg sharing and the donation of eggs leftover following reproductive treatment, will be addressed later in the paper. The decision to focus on egg donation in particular (as opposed to gamete donation more broadly) is due to the harms, risks and greater effort from donors that are involved in egg donation, in contrast to the risk-free and simple process of sperm donation. These considerations therefore make the discussions surrounding this type of reproductive donation more urgent; for whilst sperm donation involves an extremely simple process, egg donation is necessarily a far more medicalized procedure. 10 The procedure is also one that is not without risks. The London Egg
the argument that the donors themselves would be disadvantaged should IVG mark the end of egg donation as we know it today.
| IVG and egg donation
Bank notes some of these: Pelvic infection, bowel, bladder or vessel perforation, ovarian hyperstimulation syndrome, and adverse reactions to medication (including concerns over a possible (though unconfirmed) risk of eventual development of related cancers).
11
Many studies indicate that the risks are low, with one study putting the rate of "serious complications" (including "ovarian hyperstimulation syndrome, ovarian torsion, infection, and ruptured ovarian cyst" 12 ) following donation as being as low as 0.7%. 13 The same study puts the rate of minor complications serious enough to move 5 If a donor egg is used then the mother is not genetically related to the child (with the possible exception of where a donor has been used in order to pursue mitochondrial transfer interventions), however she may gestate the pregnancy as well as act as social mother after the birth. 6 Either from a friend or relative who volunteers to donate their eggs (a 'known donor'), from egg-sharing schemes (as I explore in Section 3), or from egg donation in general. 
| THE C A S E AG AIN S T EG G DONATI ON
This section argues against the continuation of egg donation once (safe, effective and inexpensive) IVG becomes a feasible alternative. This is achieved by exploring reasons why would-be recipients might opt for the use of donor eggs over having IVG (even at the expense of genetic relatedness), before arguing that the majority of these are not sufficient to justify egg donation.
| "Naturalness"
One reason why people might decide to opt to use donor eggs as opposed to IVG is to avoid that which they perceive to be "unnatural"; for as Testa and Harris note, some people view the "natural" as being "superior to the artificial or synthetic." 18 Also, some people might reject IVG treatment in favour of "the natural" alternative of donor eggs, due to having a so-called "yuck" response to the idea of IVG (or of using stem cells more broadly 19 ), and so might therefore be inclined towards the use of donated eggs, even where this would mean losing the genetic link to their future child. That this view could be held by some recipients seems to be confirmed by Hendriks and colleagues (although their study was about donor sperm rather than eggs); their findings indicate that, "The more importance couples attached to naturalness and moral acceptability, the less likely they were to opt for [artificial gametes]." 20 Further, of patients asked whether they would consider IVG treatment (if available and safe) as a "first and/or last resort treatment option," a minority said they would not, with 46% of that group preferring alternative treatment such as the use of donor sperm instead.
21
However, as many writers point out, "natural" does not always mean "better"-practically or morally. 22 As Testa and Harris note:
"the natural per se is often very harmful; disease, mutations, pestilence, floods, hurricanes, fire, landslides and the like can cause massive loss of human life and do terrible damage to the environment."
23
They argue as well that much of medicine could be considered to be "unnatural," citing the example of the heart drug digoxin, which (whilst having a natural foxglove base) is "always given in a highly purified pharmaceutical form." 24 Therefore, the argument can be made that unless one is willing to consider a "natural" disease to be morally preferable to the "unnatural" medicines that treat it, it must be agreed that the natural is not necessarily practically or morally better than the unnatural. This is not to say that the unnatural is practically or morally better than the natural, but rather that there is no intrinsic moral difference between the two. As John Stuart Mill writes: "The scheme of Nature, regarded in its whole extent, cannot have had, for its sole or even principal object, the good of human or other sentient beings. What good it brings to them is mostly the result of their own exertions."
25
Furthermore, it is important to note that "the unnatural" is ubiquitous in the world today; indeed, even farm produce cannot be considered completely natural, given the selective breeding, cloning and even induced mutation that has occurred over the centuries. 26 And just as the use of IVG techniques in reproduction might be considered "unnatural," so too could the use of a donated egg-as its use would similarly involve interventions which arguably are not "natural": 27 The egg retrieval procedure itself (and the preparation leading up to the procedure), the IVF techniques used to produce an embryo with the donated egg, and the transfer of the embryo into the uterus of the gestational mother.
This said, one might argue that there exists a sliding scale of "naturalness"-that something that is perceived as "unnatural" could nevertheless be seen as more natural (or less unnatural) than another "unnatural" intervention. So then a critic might argue that egg harvesting and IVF may well be unnatural but less so than IVG interventions and so should be preferred. However, as already noted, the natural could at best be said to be morally neutral and so the notion that one intervention might be considered to be more natural (or less unnatural) than another is not morally relevant in any case.
So then the "naturalness" argument fails both due to its faulty premise (that the natural is morally better to the unnatural), and 
| Avoiding negative psychosocial impact
Some people might opt for donor eggs rather than IVG because of concerns about the psychosocial impact that being the product of IVG interventions might have on the resulting child. 33 There may be worries, for instance, that the child in question would be more disturbed by the knowledge that they are the result of (so-called) "artificial gametes" than by the knowledge that they are the child of an egg donor (and so their social mother is not their genetic mother).
There could also be concerns regarding the reactions of others to the resulting child, especially if there is a "yuck" reaction to IVG in the general public.
One possible way of dealing with this concern is offered by
Mertes and Pennings, who suggest that parents could simply refrain from telling their children that they were the product of IVG if they were concerned about the impact that the knowledge could have- If identity is created in part through cultural narratives, and can be damaged in a morally significant way by the lack of a 'good story', then ensuring that such good stories are available to MRT children and their families becomes a collective moral responsibility... it may become necessary to establish a form of systematic monitoring to follow how the media and other social institutions discuss MRT children and families, and engage with these agencies to counter potentially hurtful, harmful or limiting identity stories with more nuanced ones based on accurate empirical knowledge.
38
Language will also be important; talk of "artificial" or "synthetic" gametes is not only inaccurate 39 but could also prove harmful, encouraging the misconception that those born of these "artificial" gametes are therefore "artificial" people. Concerns around the misleading nature of terms used in the media were also raised with regards to MRT.
40
So whilst concerns regarding the psychosocial impact of being born of IVG are reasonable, they may well be assuaged through pub- 
| Avoiding disease
Concerns regarding heritable illnesses or conditions might inform a recipient's decision to opt for using donor eggs as opposed to having IVG-for instance, where the intended parent has a predisposition to some hereditary condition. This would constitute an ethically justifi- 
| Conclusion to Section 2
Given the cases listed above, it seems that the only instances of egg donation which could be morally justified are those where mitochondrial transfer would be required, or where there are concerns regarding heritable illnesses or conditions that cannot be dealt with using PGD (or indeed where there is a moral objection to the methods involved in PGD). This being said, perhaps egg donation (as we know it today) could be replaced with IVG techniques. So if a do- circumstances, and so we might be unwilling to make an exception here as well. Although, as I will discuss in the following section, there may yet be alternative options available for those who would still prefer the use of "natural" donor eggs. Or at least the majority of members of the public.
| RE S P ON S E S IN DEFEN CE OF EG G DONATION

| 65

| Respect for wishes
One could argue that it would be wrong to rule out the use of egg donation as we know it today as we should strive to accommodate and respect the wishes of patients (and would-be recipients) where possible; parallels can be drawn with Jehovah's Witnesses here. The
Jehovah's Witnesses' interpretation of the Bible leads them to forbid their members to receive blood transfusions, so members often refuse the intervention. As a result, some surgeons endeavour to use specialist "bloodless surgery" techniques in order to be able to treat these people whilst still respecting their views and wishes. 46 One might then argue that this approach of "going the extra mile" in order to respect the wishes and beliefs of a patient in their treatment should be applied to those receiving fertility treatment who object to the use of gametes produced through IVG techniques. In short,
one could ask whether we should respect the wish to use donor eggs rather than IVG just as we do the request to have bloodless surgery:
To try to accede to it, even where it is costly.
This parity argument has some grounding in the broader literature; for instance, Juth and Lynøe write that there are no morally relevant differences between bloodless surgery and the uncommon intervention of hymen restoration, 47 and so argue that there should be parity in the provision of the two procedures. 
| Donor benefit
A second criticism is that egg donors would be disadvantaged if IVG were to spell the end of egg donation, since they themselves can be said to benefit from donating: Be that financially (by way of payment or through egg-sharing 54 schemes), or in terms of the more intangible benefits gained from egg donation. This may of course raise questions regarding the duties of doctors to persons who are not their patients, which would be beyond the scope of this paper.
52 Ibid: 9. 53 Although, if there would indeed be risk of religious or social exclusion, then this could constitute a stronger justification. 54 Where women undergoing IVF with their own eggs are offered the option to donate excess eggs to other fertility patients in exchange for subsidised treatment. 55 Such as, for example, the positive feelings that may come from the knowledge that the donation has helped someone to conceive a much-wanted child.
concerns raised by the practice being well explored in the litera- then that would be her own fully informed decision. 64 Also, again, the need for donation might not be eradicated entirely as there may still be call for donated genetic material (such as skin cells) from which gametes can be created through IVG. Therefore, donors could still obtain these benefits from donation, including those that are intangible, from this far less invasive procedure. 65 

{'paper_id': '52071356', 'title': 'In vitro gametogenesis: The end of egg donation?', 's2_url': 'https://api.semanticscholar.org/CorpusID:52071356', 'source': 'S2ORC'}