The Egg-Freezing Express

Oh, my.

The “Review” section of last Saturday’s Wall Street Journal (my paper of record) carried a piece by one Sarah Elizabeth Richards, entitled, “Why I Froze My Eggs (And You Should, Too).”  (Of course, she’s written a whole book about it.)

Egg cryopreservation has progressed to the point where human eggs do well enough in a freeze-thaw that subsequent success rates with IVF are, apparently, at least competitive with IVF using freshly-harvested eggs.  So a woman who doesn’t want to risk compromising her career, or who is having trouble finding a mate, can alleviate at least some of the pressure of the “biological clock” for procreation, and have her own eggs frozen and saved for future IVF when said mate has been found.  Ms. Richards reports that freezing her eggs helped her relax, seek a man interested in marriage, and look forward to raising a family within the bounds of what sounds like her hoped-for traditional marriage.  Apparently she has friends with similar experiences and intentions.  And she rejects the tyranny of the biological clock, while acknowledging that nothing is foolproof and motherhood can’t be postponed indefinitely in a woman’s life.

So, insofar as preserving fertility of, say, a young female cancer patient receiving chemotherapy, or—assuming you agree that IVF within the bounds of marriage is ethically acceptable—helping infertile couples, one might argue that egg freezing is a welcome development, a relatively small step that will enhance reasonable family planning and might actually discourage some couples from seeking eggs from a third-party donor.  So far, so good—or, maybe, “so far, so OK.”  (Oh, there was nothing much in the article about the process of inducing ovulation or hyperovulation with drugs, which is tacitly assumed to be risk-free.)

But of course there is no reason in principle for it to stop there.  Ms. Richards acknowledges that egg freezing can help single-mothers-by-choice, and, if a woman’s own eggs don’t survive the process, then “instead of paying tens of thousands of dollars [to an egg donor], [a woman] can buy her eggs piecemeal for a couple of thousand dollars each,” online, from one of several clinics selling eggs provided by some 300 donors.  Gee, I wonder how long before one can get a really great deal at Costco.

It all gives women power over the last area of their lives that limits their opportunity.  What’s not to like?

In an accompanying article, “The Ethics of Egg Freezing,” Christine Rosen of the New America Foundation raises concerns about complications of workplace accommodations for women and families, and she points out that the likely accompanying increase in the use of preimplantation genetic diagnosis will have people seeking “just the child [they] want by choosing its sex” or some other genetic traits.   The greater sense of control brings with it different expectations; viz., people will want the resulting child to match their expectations.  Ms. Rosen would not ban egg freezing, but she worries that if young women routinely freeze their eggs then our society “could develop very different attitudes about children and the arc of a human life.  The danger lies not in a particular technology but how it might allow us to indulge our hubris and pretend that we and our families are not subject to the relentless march of time.”

Check, check, check, check, and check.  Ms. Rosen is correct on all points.   Most people don’t believe in the providence of God anymore, but they do believe in the providence of man (and woman).  (Oh, BTW, over at his “Human Exceptionalism” blog, Wesley Smith recently took to task a recent New England Journal of Medicine piece promoting the sale of made to order embryos.  And Ms. Rosen didn’t comment—as well she might have—that such control, such ‘autonomy,’ could readily come under control of the state someday.  “Ms. Smith, do you have your government-approved pregnancy permit?”)

I don’t pretend that this freight train will stop.  And I would not try to ban egg freezing—for eventual use in, say, gamete intrafallopian transfer.  Old fashioned and inefficient, I know.  But I am convinced that human IVF was a line we ought never to have crossed.  Having crossed it, I agree with the Roman Catholic commentators who argue it is a practice of which followers of Christ ought to repent.  (I know I am at odds with received evangelical opinion here.)   And we must promote an attitude that children are a gift, not a product.  And we must raise our kids and encourage people in general that procreation is properly limited to true marriage—as describe by Robert George’s group, a complete union of husband and wife, body and soul, uniquely ordered for procreation and the raising of children, necessarily exclusive and permanent.

Let’s lean into that.

A Place Where We Ought to Fear to Tread

The current issue of World magazine includes a brief article about this work going on in the United Kingdom: attempting to circumvent certain inheritable diseases by replacing the mitochondrial DNA in a mother’s oocyte with mitochondria from an oocyte of another woman.  The re-engineered oocyte is then fertilized in vitro, with subsequent implantation of the embryo, etc, etc.  The article’s provocative title was, “Heather has two mommies.”

If one accepts IVF and is inclined to observe the “therapeutic boundary” as placing limits on what genetic manipulations we should be willing to undertake, then this project would seem to qualify as treatment, rather than enhancement, before a new individual person is conceived, and could qualify as an acceptable use of reproductive technology.  And one can argue that the risk/benefit analysis, in a case like this, is clearly positive (perhaps requiring that all embryos so created are implanted with the intent to carry them to term).

But I’m not so sure that a line has not been crossed here.  Still, to object on grounds of “repugnance”—as I would—would seem to succeed only if said repugnance reflects deep, universal moral sentiments and intuitions that are expressions of a natural moral law.  And a lot of people would not find the case here repugnant.  To object—as, again, I would—on the grounds that the undertaking here is part of the transformation of procreation (and receiving of new life as a gift) into manufacturing seems to require that there is an objective, given, human nature and order of human life that must not be tampered with.  If life is God-given and humans are in His image, then it is more natural to make that kind of assertion, but by so doing I think we (I) accept the task of saying what that human nature is.  The image, in that case, needs to be more than just a “status and standard,” or to say that it grounds the human nature we shouldn’t mess with seems tautological.  Alternatively, on more naturalistic grounds, one might argue that evolution “gave” us a core genetic nature (“in its wisdom??”) that “ought not be disposed with,” a tack the German philosopher Jürgen Habermas seems to take in opposing PGD.  Or, we could even invoke a form of the much-maligned “precautionary principle” and claim that, when we start mixing and matching pieces of genomes in newly-conceived people, we don’t know what difficulties we might be wandering into, so we can’t define a risk-benefit ratio in the first place.

Anyway, I think a line something like this—there is, in a meaningful sense, a “core human nature” that must not be altered, and a natural moral law that grounds at least the most basic, primary moral precepts setting that limit—is the line that is necessary if one wants to claim that our biotechnologic grasp must stop somewhere.  And so I want to hold.  None of it suggests that the march of biotech will be slowed—it seems that somebody will try anything that becomes feasible—but it is a basis for asking people to stop and think, and getting perhaps some to turn back.  It is a basis for articulating a “presumption to forbear.”

Payment for egg production

A California bill to reverse a 2006 state law that restricts payment to women who produce eggs for research to no more than payment of direct expenses is in the news. It highlights several interesting ethical and societal issues. The current legal status of payments for human eggs in California is interesting. It is currently legal to pay a woman $10,000 or more to provide eggs for use by another woman in fertility treatment, but illegal to pay more than expenses for eggs used for research. That seems odd. In countries such as Canada where it is against the law to pay for human eggs it is illegal for whatever reason it is being done.

The arguments against paying women to procure their eggs are strong. Egg harvesting is an invasive procedure and the hormonal treatment required to cause production of multiple eggs for harvest carries significant risk to the woman involved. Many women with infertility problems are willing to take that risk in order to conceive and bear a child. However, there is reason to be concerned that women with financial needs will be exploited by being lured into risking their health for the amounts of money that are paid for eggs. Our society does not allow donors of organs for transplant to be paid out of similar concern about exploitation. To that can be added concerns about turning the bodies of women into a commodity to be sold to the highest bidder. It is demeaning to those so used to consider a person’s body or a part of that body a commodity to be sold. If these arguments hold then paying women to produce eggs for others to use should be prohibited to protect women from being exploited whether the eggs are being used for research or for reproduction.

However, something else is at play in California and the rest of rest of the US. Our society has bought into the idea that the desire to have children supersedes all other moral concerns. It is part of a more general idea that our freedom to make autonomous decisions regarding our sexuality and reproduction should not be limited in any way. That has caused the United States to have an entirely unregulated assisted reproduction industry. Whereas most technically advanced nations have significant regulation over what can be done in relation to IVF and other reproductive technology, there is no regulation here. While we also place a high value on science and research, the history of dramatic cases of exploitation of people for research in Nazi Germany, the Tuskegee study and other situations has sensitized our society to the need to regulate human research. We have created a whole system of regulations to protect potential research subjects. Thus it was quite feasible for those who saw the danger of exploitation of women being paid to produce eggs to pass a law restricting payments to those who produced eggs for research, but not feasible to restrict payment for eggs for reproduction.

An obvious argument for those who want to overturn that law is that it makes no sense to limit payment to women who produce eggs for research when those same women could be paid $10,000 or more to produce eggs for reproduction. They are correct that it does not make sense to differentiate between the two, but it is not the limitation of payment for eggs for research that needs to be addressed. What we as a society need to address is the idea that the autonomous choice to have a child by whatever means possible should always be allowed. Children should be highly valued, and having children can be an amazing blessing. Infertility can be devastating to those who desire to have children but cannot. But having children is not an end that justifies every possible means to fulfill that end. There are some things we should not do even to have children. One of the things we should not do is paying women to risk their health to provide eggs so other women who want to have children can have them.

German debate about PGD

A recent article from Spiegel Online which is on the ABC News website discusses the debate about pre-implantation genetic diagnosis in Germany. Pre-implantation genetic diagnosis (commonly abbreviated PGD, but abbreviated PID in the article) is a technique in which one or a few cells are removed from a developing embryo produced by IVF and tested for genetic abnormalities. In the context of the discussion in Germany it is being used to allow parents who are known to be carriers of a serious genetic disorder to choose to give birth to a child without that disorder by choosing an embryo to implant who does not have the disorder from among the ones produced. Unlike the US, Germany carefully regulates reproductive technology and until 2010 PGD was illegal. A court ruling in 2010 led to a parliamentary amendment to Germany’s Embryo Protection Act to allow PGD to be used legally in exceptional cases in which parents are at high risk to have a child with a serious genetic disorder that can be detected by PGD.

Not everyone in Germany thinks this is a good idea. The arguments against PGD reported in the article come from medical ethicist Axel Bauer who wrote that he fears “that the possibilities PID offers will significantly reduce the range of ‘normality’ that will still be tolerated in our society in the future.” Hubert Hüppe, the German government’s commissioner for the disabled, says critically: “In the future, human life will only exist after quality control.”

Elke Holinski-Feder founder of the Medical Genetics Center in Munich that provides the genetic services for PGD says “I have a feeling that many of those who pass judgment on PID don’t know what we are doing here.” She says that those who oppose PGD are concerned about what it might lead to in the future, but she is concerned about parents who want to have a child but know through the experience of having a child who has died from or is living a very difficult life with a serious genetic disorder. She wants to be able to offer them the ability to have another child who is free of that disorder. Her argument is essentially that as long as PGD is limited to allowing those parents who are at high risk to have a child with a serious disorder to have a child without that disorder it should be allowed. That limitation removes the fear of reducing the range of acceptable normality in society since those detectable genetic disorders are only a small fraction of congenital abnormalities and would not allow the use of PGD as quality control. She says that going beyond that limited use, as is done in the US, would be wrong, saying “making a little sibling to be a donor for a child with leukemia, that’s not okay.” She adds that there are other ways to help those children.

What seems to be missing in this discussion is concern about the value of the life of the embryos that are discarded in the process of PGD when they are found to have a genetic abnormality. In her comments in the article Holinski-Feder does express concern about using prenatal diagnosis and abortion as a method for screening for the same genetic disorders. She says “Do you know what advice these families are usually given? Try it, and if it goes wrong, terminate the pregnancy!” She explains that is not the advice she wants to give her patients and sees PGD as a better solution. The only reference to the value of human embryos in the article is when Holinski-Feder says that when her students ask her: “When does human life begin?” she responds with a series of questions: “Imagine you were asked to place a picture of yourself as a child on the shelf. Which picture would you use? The zygote? The embryo? The baby?”

While concerns about the morally problematic things to which PGD opens the door are legitimate concerns, the most significant ethical concern about the use of PGD is the embryos that are discarded. For those who believe that human embryos have full moral status, destroying them for any reason is wrong. Even for those who do not think that human embryos have full moral status, a human embryo is a living human organism whose unique identity is continuous with the human person that the embryo will be after gestation and birth. To discard an embryo is to say that the life of that unique human being has no value or that his or her life is not worth living. That is something that the German people should be especially sensitive to avoiding since it was the concept of a life not worth living as expressed by German philosophers in the early 20th century that was the foundation for the elimination of mentally disabled children early in the Nazi regime and the springboard for more extensive atrocities.

Surrogacy: Begotten or Made?

In 2010, the last year with data available, there were about 859 reported in vitro cycles initiated using a gestational surrogate in the United States.[i] Each year since 2007 the number of IVF cycles using a gestational surrogate has increased with the practice becoming more widely known and socially accepted.[ii]  These numbers, though, are underreported since the data only reflect surrogacy initiated through IVF and only take into account IVF clinics that are members of the Society of Assisted Reproductive Technology.

There are many terms floating around in connection with surrogacy.  For purposes here, traditional surrogacy represents surrogacy initiated through artificial insemination and use of the surrogate’s gametes.  Gestational surrogacy differs from this for it typically involves IVF using the contacting parent’s gametes or the gametes of a donor.

Further still, I will be speaking only of altruistic surrogacy (surrogacy wherein the surrogate is not compensated for the child to whom she has given birth, but may be compensated for medical expenses and gestational services rendered) as opposed to commercial surrogacy (compensation for all of the above including payment for the child).

One common argument against surrogacy is that it makes a strange or unnatural familial unit.  For example, the surrogate may be the biological grandmother or aunt of the child or the surrogate may not be any relation to the family at all.  This, then, places the child in the awkward situation of not knowing whom s/he should consider his/her mother.

Another argument against surrogacy is that it works best when the surrogate mother is emotionally detached from the baby so that after the birth she is able to hand the child over to the contracting parents with no or reduced emotional difficulty.  The obvious problem with this, though, is that this is not healthy for the child in utero to have an emotionally detached mother.

Finally, opponents of surrogacy view this arrangement as a violation of the one-flesh relationship.  That is, the familial unit is corrupted when gametes and/or wombs of other individuals are used to produce a child.

These are all functional arguments commonly used against surrogacy.  The problem, however, is that all of these arguments could be applied to adoption.

Adoption confuses the familial unit especially in cases wherein grandparents, parents, aunts, uncles, cousins, etc. are asked to raise a child on behalf of another family member who is unable to parent.  Oftentimes the pregnant woman must detach herself from her child while in utero so that on the day of the adoption she may place him/her with the adoptive family.  Finally adoption most definitely violates the one-flesh relationship because gametes and wombs other than those of the adoptive parents are being used.

No Christian, however, would be willing to argue against adoption.  It is quite the contrary!  The theme of adoption runs through scripture from Old Testament to New.  A short list of examples include people such as: Moses, Esther, Jesus, and last but not least, those of us Gentiles who have been grafted in.

So what do we do when our own arguments against surrogacy preclude adoption?

The fundamental difference between surrogacy and adoption is children who are made versus those who are begotten.  Children made are those who have been solicited by a contracting couple.  Those begotten have been conceived free from solicitation of another woman’s womb, gametes, or another man’s sperm.  It is here, in the distinction of begotten and made, that arguments against surrogacy should lie.  (It is important to note that children retain their dignity and continue to image God no matter the circumstances under which they were conceived.)

To make the distinction more clear, adoptive parents receive their child as a gift—a gift that does not have to be fashioned by them or fashioned to be like them genetically.  Contracting parents, on the other hand, accept their child as a product built to their specifications.

Solicitation, on the outside, may not appear problematic because the contracting parents clearly and desperately want the child.  However, is being wanted the greatest good or even what is best for the child?  Children made through these artificial means have a compromised right to an open future.  Adoptive parents, on the other hand, accept their adopted child for who they are instead of determining from the beginning who they should be.

 



[i] “Clinic Summary Report,” Society for Assisted Reproductive Technologies, accessed January 24, 2013, https://www.sartcorsonline.com/rptCSR_PublicMultYear.aspx?ClinicPKID=0.
[ii] Ibid.

Definitions matter

Sometimes ethicists and philosophers seem to be overly concerned about the definitions of the words we use, but how we define words can make a significant difference in ethics. This has recently been illustrated by a ruling of the Inter-American Court of Human Rights (as reported in Nature News Blog) which struck down the prohibition of IVF by the Costa Rican constitutional court. It is interesting that the Inter-American Court of Human Rights was created by the American Convention on Human Rights which was adopted in 1969 in San Jose, Costa Rica.

Article 4.1 of that document states “Every person has the right to have his life respected. This right shall be protected by law and, in general, from the moment of conception. No one shall be arbitrarily deprived of his life.” The Costa Rican court had based its prohibition of IVF on the fact that IVF denies that right to life of many fertilized eggs that are not implanted. The Inter-American Court of Human Rights struck down Costa Rica’s prohibition of IVF by redefining the term conception in its foundational document to mean the time after implantation and not the time after fertilization.

This serves as a reminder that we live in a time when people in power not only believe in ethical relativism, but in post-modern relativism of language as well in which words can be redefined to fit their purpose. We must remember that our stand for truth involves not just the truth of objective moral values, but also the truth of the meaning of the words we use to express those values.

The Whitewashed Tombs of the Right

“Woe to you, scribes and Pharisees, hypocrites! For you are like whitewashed tombs, which outwardly appear beautiful, but within are full of dead people’s bones and all uncleanness.”– Matthew 23:27

I received several comments on last week’s post about Hubertus Strughold, so I thought I’d follow up with another post.  The fact that Strughold has been well-respected in American medical circles despite his leadership in medical experimentation in Nazi Germany may shed light on deep-seated philosophical problems that undergird America’s healthcare crisis.  It is no secret that the Allies marveled at the technological and scientific capabilities of the Germans as they marched through that country in the final days of World War II.  Though it used the scientists of the Third Reich to the ultimate success of putting a man on the moon, American medicine may also have adopted harmful philosophical ideas that cripple U.S. medicine to this day.  The technological and scientific accomplishments of American medicine may be the whitewash that hides the philosophical problems that are the dead people’s bones that affect patient care and make us incapable of solving systemic healthcare problems.

Dachau, notorious for its human experimentation

Several writers on this blog have commented on the failures of the “business model” of medicine.  Joe Gibes has written several posts on the subject (see his “Black Friday” post), and Steve Phillips has recently mentioned the “manufacturing efficiency” that has been brought to human reproduction.  It is well-known that many Americans sided with the National Socialists in Germany in the 1920s and 30s because they saw them as a bulwark against the tide of communism that seemed to be sweeping over Europe (Russia fell to the Communists in 1917).  In the culture wars in America the last two decades, it appears the right-wing has propelled the “business model” of medicine to the fore as a bulwark against the Left’s move to bring government-run healthcare to America.  It is a classic case of the end justifies the means.  Why Christians allied themselves with the right-wing to form the “Religious Right” in the 1980s I’ll never know.  But it looks like a deal with the Devil.

Bargain priced IVF with a money back guarantee

An infertility clinic in California has come up with a new marketing strategy for IVF. The Los Angeles Times reports that the clinic offers up to three rounds of IVF using embryos produced in batches from paid sperm and egg donors and uses the embryos to implant in multiple women to reduce the cost of having an IVF baby to $12,500 with a guarantee that if the recipient is not able to achieve a pregnancy after three tries the fee will be refunded. The lower than usual cost is achieved by splitting the cost of obtaining the eggs and sperm between 3 or 4 recipients for each batch of embryos, and the success rate of 95% with half of the recipients having twins makes the money back guarantee feasible. The high success rate is due to the use of eggs and sperm from healthy young adults without known fertility problems. It appears that mass production and industrial efficiency has found its way to the IVF clinic.

The ethical concerns are legion. The embryos are created as a product to be sold by the clinic and belong to the clinic, not to parents until they are implanted. The selling of eggs and sperm is concerning because it commodifies a part of a human being. This process commodifies the embryos themselves. The recipients are given profiles on the sperm and egg donors and it does not take much imagination to see how this process could be used to order the child that a couple desires from a catalogue. At this point the money back guarantee is for a successful pregnancy, but it opens the door to a guarantee of an acceptable child. Can you take the child back in adolescence if he or she is not what you expected? Some parents may already be tempted to think about that.

The use of eggs or sperm that are not those of the parents who will be raising the child causes confusion of family relationships for the child. One wonders if the clinic should be considered a fifth parent for the child in addition to the two biological donor parents, the gestating mother and her partner (assuming she has one). How is the child supposed to react to the knowledge that he or she has multiple fraternal twins (octuplets or more) in existence being raised by unknown families who he or she may run into in the future?

As long as the production of babies is seen as an industry it is inevitable that manufacturing efficiency will play a role and human lives will be sold as commodities. And the value of all of us as human beings is diminished.

Eugenics and the genetic testing of embryos and fetuses

In a recent article in the Australian media Julian Savulescu, a noted Oxford ethicist who is a visiting professor at Monash University in Melbourne, makes the contention that selecting which babies are born by doing genetic testing on embryos or fetuses and only allowing those that are desired to live to birth in the way that it is allowed in Australia shares the moral problems of past eugenics programs that we have rejected. His point is that the current practice in Australia allows selection of embryos by preimplantation genetic diagnosis and fetal testing with selective abortion only for diseases and not for sex selection or other non-disease characteristics. By allowing selection based only on diseases the society is saying that “lives with disability are less deserving of respect, or have lower moral status.” That is why we rejected the eugenics programs of the past.

Savulescu points out that “If either the embryo or the fetus has a moral status – then it would be wrong to kill either, whether or not a disability is present. If the embryo or fetus does not have a moral status, it should be permissible to destroy an embryo or abort a fetus for any reason. In this way, paradoxically, allowing testing for diseases, but not for other genes, is eugenic in objectionable ways.”

It would be easy to go from there to saying that genetic testing of embryos and fetuses for the purpose of selecting who will be allowed to be born should not be done based on the principle of the value of all human lives underlies our rejection of eugenics, but he does not go that direction. Instead he moves toward the permissibility of all embryonic and fetal testing by saying that lifting the restrictions on personal liberty imposed by limiting genetic testing of embryos and fetuses to testing for disease would resolve the moral objection that the current policy involves morally impermissible eugenics. He gets there by saying that since most people already accept the testing of embryos and fetuses for diseases, we should not say that all such selective testing is wrong based on the moral status of embryos and fetuses and the way to validate people’s acceptance of testing for diseases is to allow testing for non-disease characteristics.

Savulescu’s means of getting to his conclusion is an interesting and commonly used one to justify things that have previously been understood to be wrong. Rather than giving arguments for why we should believe that a human embryo or fetus does or does not have full moral status, he says we have already accepted a limited practice that would otherwise have been considered immoral, so we should accept a broader version of the same sort of practice. This is the process by which immoral behavior takes over a society, and also the process by which an individual falls into immorality. First justify a very limited violation of morality, and then once that is accepted use that to justify further immorality.
That is why we need to stand firm on basic moral values such as the dignity and value of every human life. Defending the moral status of the weakest and most defenseless human beings is essential to avoid the acceptance of things like aborting fetuses because they are female that currently seem obviously wrong, but may become accepted by a gradual breakdown of moral values.

Moral status vs. moral agency

A recent post about the personhood of human embryos made me think about the distinction between moral status and moral agency. Moral status relates to how we should treat an individual who has it or does not have it. Moral agency has to do with whether the individual is capable of making decisions or doing actions for which the individual is morally responsible. Both are characteristics that an individual being or type of being may or may not have. Most would say that any being that is a moral agent should be considered to have full moral status. That means that any being who is able to be held morally responsible for its choices and actions should be treated as having the same moral value as myself. However, there may be some individuals who have full moral status, but are not moral agents. That would mean that such an individual is a person who should be treated by me as having the same moral worth that I have even though that person is not morally responsible for his or her own actions. Some examples of those who we commonly understand to have full moral status, but who are not moral agents, include young children, those who have a mental disability that makes them unable to understand the difference between right and wrong, and those who have dementia or even temporary incapacity to make moral decisions.

When we as Christians take the position that a human embryo has full moral status because that embryo is a member of the human family who has been made in the image of God, we take that position understanding that an embryo is not a moral agent. I think that one of the reasons for the problems with capacity definitions of moral status like the one used by May Ann Warren is that it confuses moral status and moral agency. Being a moral agent is totally dependent on the capabilities of the individual. It depends on having the ability to understand the concept of right and wrong, the reasoning capacity to determine what actions are right, and the ability to control his or her actions. If one assumes that moral status is similar to moral agency then it makes sense for there to be similar capacities that determine who has moral status. But moral status is a totally different type of thing. It has to do with the nature of a being not its capabilities. How we treat something morally has to do with what kind or category of being that the individual is and that is not dependent on its capabilities. That is why we treat children and the disabled as full human beings even though they are not moral agents. That is why we should treat human embryos the same way.