Accessing Reproductive Technologies: Invisible Barriers, Indelible Harms

The use and success of assisted reproductive technologies (ART) over the past decade has contributed perceptibly to family formation nationwide. Today, 3 of every 100 children born owe their existence to some form of assisted conception. Despite, or perhaps because of, its technical successes, a growing body of evidence suggests that barriers to ART are being constructed to prevent procreation among select populations. The article’s theme is one of harm, specifically the harm that befalls patients, physicians, offspring and society when fertility treatments are denied on the basis of personal characteristics, including race, marital status and sexual orientation. While ART is widely perceived as a free market good, the provision of reproductive services is increasingly subject to public and private barriers that target prospective parents whose procreative rights have been historically dismissed or undervalued. These barriers create limitations to treatment based on patient immutable characteristics and social structures, ultimately imposing undue burdens of the affected individual’s right to procreative liberty. The central portion of the paper analyzes the harms from ART denials to four distinct cohorts – patients, providers, offspring, and society - suggesting possible solutions to address or forestall the offending conduct. Harms to patients from treatment denials include forced childlessness as well as dignitary harms, the latter arising when the fundamental right to procreative decision-making is repressed. Harms to ART providers take the form of economic and reputational loss, amenable to repair only by adhering to established norms governing physician autonomy which balance patient and provider needs. Harms to offspring encompass damage to existing and never-born children, diminishing the life and potential existence of children conceived through technological means. Finally, harms to society are reminiscent of the damage inflicted by the American eugenics movement of the early 20th century. Today’s deprivation of reproductive opportunity is compared to the coercive sterilization tactics of yesteryear, reminding us that seemingly well-meaning expressions about the welfare of the human race may be a pretext for nefarious social engineering aspirations

Predictors of SARS-CoV-2 RNA From Nasopharyngeal Swabs and Concordance With Other Compartments in Nonhospitalized Adults With Mild to Moderate COVID-19

Background Identifying characteristics associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA shedding may be useful to understand viral compartmentalization, disease pathogenesis, and risks for viral transmission. Methods Participants were enrolled August 2020 to February 2021 in ACTIV-2/A5401, a placebo-controlled platform trial evaluating investigational therapies for mild-to-moderate coronavirus disease 2019 (COVID-19), and underwent quantitative SARS-CoV-2 RNA testing on nasopharyngeal and anterior nasal swabs, oral wash/saliva, and plasma at entry (day 0, pretreatment) and days 3, 7, 14, and 28. Concordance of RNA levels (copies/mL) across compartments and predictors of nasopharyngeal RNA levels were assessed at entry (n = 537). Predictors of changes over time were evaluated among placebo recipients (n = 265) with censored linear regression models. Results Nasopharyngeal and anterior nasal RNA levels at study entry were highly correlated (r = 0.84); higher levels of both were associated with greater detection of RNA in plasma and oral wash/saliva. Older age, White non-Hispanic race/ethnicity, lower body mass index (BMI), SARS-CoV-2 immunoglobulin G seronegativity, and shorter prior symptom duration were associated with higher nasopharyngeal RNA at entry. In adjusted models, body mass index and race/ethnicity associations were attenuated, but the association with age remained (for every 10 years older, mean nasopharyngeal RNA was 0.27 log10 copies/mL higher; P < .001). Examining longitudinal viral RNA levels among placebo recipients, women had faster declines in nasopharyngeal RNA than men (mean change, −2.0 vs −1.3 log10 copies/mL, entry to day 3; P < .001). Conclusions SARS-CoV-2 RNA shedding was concordant across compartments. Age was strongly associated with viral shedding, and men had slower viral clearance than women, which could explain sex differences in acute COVID-19 outcomes

Bamlanivimab therapy for acute COVID-19 does not blunt SARS-CoV-2-specific memory T cell responses

Despite the widespread use of SARS-CoV-2-specific monoclonal antibody (mAb) therapy for the treatment of acute COVID-19, the impact of this therapy on the development of SARS-CoV-2-specific T cell responses has been unknown, resulting in uncertainty as to whether anti-SARS-CoV-2 mAb administration may result in failure to generate immune memory. Alternatively, it has been suggested that SARS-CoV-2-specific mAb may enhance adaptive immunity to SARS-CoV-2 via a "vaccinal effect." Bamlanivimab (Eli Lilly) is a recombinant human IgG1 that was granted FDA emergency use authorization for the treatment of mild to moderate COVID-19 in those at high risk for progression to severe disease. Here, we compared SARS-CoV-2 specific CD4+ and CD8+ T cell responses of 95 individuals from the ACTIV-2/A5401 clinical trial 28 days after treatment with 700 mg bamlanivimab versus placebo. SARS-CoV-2-specific T cell responses were evaluated using activation induced marker (AIM) assays in conjunction with intracellular cytokine staining (ICS). We demonstrate that most individuals with acute COVID-19 develop SARS-CoV-2-specific T cell responses. Overall, our findings suggest that the quantity and quality of SARS-CoV-2-specific T cell memory was not diminished in individuals who received bamlanivimab for acute COVID-19. Receipt of bamlanivimab during acute COVID-19 neither diminished nor enhanced SARS-CoV-2-specific cellular immunity

A Clash at the Bedside: Patient Autonomy v. A Physician\u27s Professional Conscience

Advances in medical science and technology have enabled physicians to effectively sustain patients\u27 biological existence without curing or relieving their underlying illnesses. In some cases, physicians may perceive the application of these advances as medically futile or inappropriate. However, the jurisprudence of medical decision making has focused on patient autonomy, often giving patients the right to demand whatever treatments are available, regardless of cost, prognosis, and the advice of their physician. Professor Daar examines the role a physician\u27s professional conscience plays in the jurisprudence of medical decision making. After criticizing the courts\u27 inconsistent response to a physician\u27s assertion of professional conscience, she turns to an examination of legislative responses to patient-physician conflict in the context of abortion refusal statutes, which recognize and protect the exercise of a physician\u27s professional conscience. She argues that our jurisprudence should offer this protection for physician autonomy in a wider clinical setting. Professor Daar concludes with a proposal, adapted from a model currently in place to resolve conflicts between attorneys and their clients, to resolve patient-physician conflicts without denigrating either the patient\u27s autonomy or the physician\u27s professional conscience