Who Lives, Who Dies, Who Decides…

I just finished reading a very dry book on organizational theory as applied to reproductive medicine. The book was a Swedish observational study evaluating the sociomaterial aspects of that subspecialty, particularly Swedish IVF clinics. While the book did not directly address ethical issues in reproductive medicine, it did note some of them in passing. One that caught my eye was issue of the choice of the embryo to be placed into the womb. In Sweden (unlike the US), the standard is, and has been, single-embryo transfer, so one embryo must be chosen from the many created for the privilege of transfer to the womb. While genomics and metabalomics are factors in this highly regimented and scientifically technical field, the ultimate choice of embryo—of which living being gets the first shot at life—is made, not on the basis of scientific evidence or quantifiable parameters, but on “morphological analysis”—on vision and appearance—the subjective vision of the laboratory technicians as they evaluate the appearance or form of the embryo.

Some of the visual qualities considered include the number and size of the cells for the stage of growth, roundness, symmetry, degree of fragmentation (cellular garbage), multi-nucleation, and so forth. But ultimately it becomes a matter of which one appears to have the best form.

Disturbingly, there are times when none of the embryos “appears” to be optimal, but one is still chosen and placed into the womb; and some pregnancies do result from the use of these “sub-optimal” embryos. But no mention was made of any studies of the outcomes of such pregnancies—were the pregnancies ultimately successful? Were the babies who were born of such pregnancies healthy? Perhaps more significantly, when such “suboptimal” transfers are performed—suboptimal in the eyes of the beholder–the prospective parents are neither notified nor given the choice of not proceeding: consent is assumed. Should they be given “informed consent” on the basis of little or no “knowledge”?

The hubris involved in such actions is sobering. In our fallen world we are all suboptimal beings. But because we have ventured down this path—because we have sought to intervene in the hidden recesses of life—no doubt enabling some to have a child of their own who otherwise may not have had that opportunity—we place ourselves in the position of having to judge the worth of a life. A sociomaterial perspective—one in which the embryo is not a living being, but merely a conglomerate of organic human material—is no doubt helpful, enabling those involved in this business to justify their role as judge of which conglomerate should be given a chance at life and which should not.

In this medical age where we deceptively demand objective, concrete evidence to justify all that we do, we continually refuse to acknowledge that even the best of our “evidence” is corrupted with subjectivity from beginning to end. Despite our best efforts, subjectivity cannot be removed from human moral endeavors: it is inherent in anything and everything we touch. It is therefore ironic that in a cultural age in which we insist that people should not be judged on the basis of appearance (skin color, nationality, gender, dress) we rely solely on the basis of appearance for judging those worthy of a chance at continued life. It is even more ironic in this scientific age, that in this most vital of choices we judge solely on superficial appearances in the eye of the beholder—and believe ourselves capable and worthy of doing so.

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