Thoughts on varied subjects: commercial surrogacy, professionalism, and Obamacare

A potpourri of stories from this week that prompted bioethical musings, in no particular order . . .

The BBC News website ran a fascinating, heartbreaking story this week about women in India who are paid to gestate other women’s babies: commercial surrogacy, a billion-dollar-a-year industry in India. The main figures in the story — a woman named Vasanti living in a dormitory for commercial surrogates, who is carrying a baby for a Japanese couple; and the doctor who runs the IVF clinic and dormitory — spend much of the story talking about how positive the practice of surrogacy is. Thus it is jarring — and revealing —  to get to the last sentence in the story, where Vasanti says, “. . .we want a good future. That’s why we [did] this, and not in my entire life do I want my daughter to be a surrogate mother.” (Italics mine)

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Last week’s JAMA ran a narrative by Gordon Schiff, MD, which begins,

It’s 5 PM on a Friday afternoon. After 2 hours on the telephone trying (and failing) to get her insurance plan to pay for her medication refill, I reached into my pocket and handed the patient $30 so she could fill the prescription. It seemed both kinder and more honest than sending her away saying, “I’m sorry I can’t help you.” While I hardly expected a commendation for such a simple act of kindness, I was completely surprised to find myself being reprimanded for my “unprofessional boundary-crossing behavior” after the resident I was supervising shared this incident with the clinic directors.

(If you have a JAMA subscription you can read the whole thing here, otherwise it has been reposted for free  here.) Dr. Schiff’s reflections on this incident are eloquent and worth reading and pondering. From the perspective of a Christian physician who also works with the underserved, I am saddened at how far our profession strays from its moral foundations when  a detached, medicine-as-business model replaces the self-giving care that Christ modeled.

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You may have missed it, but new provisions of the enormous law affectionately known as “Obamacare” went into effect this week with the beginning of open enrollment and the opening of online insurance marketplaces. The new law is extremely complex and promises to raise health insurance costs for many, including myself, at least in the short term. Lots of people are complaining about it, some more savagely than others. Many of my colleagues and patients have bemoaned it, and with good reason. But there is one group who have not complained to me about it at all: my patients who do not have, and until now have not been able to afford, health insurance.

On forced procreation and the right not to be a father

Wednesday’s Chicago Tribune ran a story on the top of the front page: “Couple battle over frozen embryos.” It is a tale that has been told many times in many places, with slight variations in the details: woman finds she has cancer; chemotherapy will end her fertility; boyfriend donates “genetic material” and, using her eggs and IVF, they make embryos; boyfriend and girlfriend split up; now she wants to implant embryos, but he wants embryos destroyed; Illinois Supreme Court to weigh in.

The boyfriend claims that “he never agreed to give up a say in whether he becomes a parent, that forced procreation would violate his constitutional rights” (italics mine). The Tribune story quotes him as saying, “I have the right not to be a father.”

Whoa, wait a minute. Forced procreation? The way I read the story, nobody was holding a gun to his head when he made his donation.

Nobody is denying that he has a right not to be a father. But it seems to me that he relinquished that right the moment his “genetic material” met her egg, and made a third party, a separate embryonic human. In other words, it’s too late — He already is a father.

If there is a “right” not be a father, it is the right to avoid fatherhood by avoiding going around fertilizing ova, not the right to avoid fatherhood by killing one’s offspring.

 

Stem cell programming inside the body

On August 29, I wrote about research into developing germ cells (sperm and eggs) from induced pleuripotent stem cells (iPSCs) that were developed in the laboratory and injected into mice.  I mused about some potential implications for assisted reproductive technologies and the like.

A broader area of stem cell and regenerative research seeks to use drugs or other approaches to reprogram cells within the body, without having to remove them and manipulate them or culture them in the laboratory.  One application would be to develop a drug that would induce certain stem cells in the body to develop into cells that had been damaged or lost in a disease process.

Last week, Nature published a paper online from a group in Spain that had succeeded in reprogramming cells in adult mice.   A brief, free summary is here; the full article is available to subscribers or for purchase online.

Now, at present, iPSCs can be induced by treating mature cells to express four genes that, when expressed, cause the mature cell to “de-differentiate” into an immature, pleuripotent state.  A pleuripotent cell is capable of developing into any type of cell found in a given, fully formed organism; i.e., a pleuripotent human cell is capable of becoming any kind of human tissue.  But pleuripotent cells can’t become a whole new individual.  For that, a “totipotent” cell is required.  A zygote—a fertilized egg cell—is a totipotent cell.  Early on in embryonic development, cells lose totipotency, but retain pleuripotency.   In fact, embryonic stem cells obtained by destroying a human embryo generally are not able to develop into a new embryo.   (Apparently, iPSCs generated in vitro have been said to be transiently totipotent, but generally iPSCs are not totipotent.)

What is remarkable about last week’s Nature report is that it looks like the researchers obtained not just iPSCs, but totipotent cells, by a technique designed to give rise to iPSCs in an intact mouse.  They derived “transgenic” mice—mice that have extra genes—that express the four genes needed to induce a mature cell to become an iPSC.  The mice were engineered so that their extra genes—their “transgenes”—were under the control of a genetic switch that turned on the transgenes if an antibiotic, doxycycline, were given to the mice.  That’s easy:  just put the antibiotic in the drinking water.  No antibiotic, the genes were off, and the mice were healthy, for at least 2 years, as if they had not been engineered.  Too much antibiotic, and the extra genes were “on,” full blast, and the mice lost weight and died.  But give an intermediate dose, and the genes were switched on just the right amount that the mice were riddled with “teratomas.”

A teratoma (from the Greek “teras,” or “monster,” and the suffix oma, meaning “tumor”) is an uncommon human tumor that usually does not metastasize, like cancer, although it can.  It arises from pleuripotent cells—germ cells and embryonal cells.  It is one of those oddities that pathologists routinely show to medical students, and they’re wild, because they can contain, chaotically,a mix of mature tissues—bone, kidney, muscle, hair, the occasional tooth, or whatever.

In the experiment in question, the transgenic, sufficiently switched-on mice had teratomas in all sorts of tissue, arising from different organs.  In other words, they had iPSCs crop up, and grow into tumors, in various organs inside their bodies.  The researchers were able to obtain these iPSCs from blood samples obtained from the mice—so they were circulating.

But now it gets wild.  First, these in vivo iPSCs were genetically more similar to embryonic stem (ES) cells—obtained from an actual embryo—than to iPSCs derived in vitro.  Moreover, like ES cells but unlike in vitro iPSCs, these in vivo iPSCs were able to form placenta cells.  And—get this—when injected into the abdomens of normal, non-transgenic, “wild type” mice, the in vivo iPSCs, unlike the ES cells or in vitro iPSCs, developed early embryos.

So, the in vivo iPSCs are much more versatile than ES cells or the iPSCs we may have become used to referring to.  As with any early research, translation into a medical application is some way off, but one can in theory envision a future treatment to induce these cells in a sick person, harvest the cells from the blood stream, and use them to treat a disease.  (There’s a sweeping statement for you, and admittedly so.)  But the apparent totipotency of these cells suggests a new wrinkle on cloning, for one.

Germ cells from “ethical” stem cells

What expertise I have is not in cell or developmental biology, nor in stem cell research.  But I try to follow developments.  As I do, I’m learning two humbling lessons:  it’s next to impossible to keep up, and you can’t make this stuff up.

Consider the work, summarized in a report in Nature last week (accessible to the public without subscription), regarding the use of stem cells to study how germ cells (sperm and eggs) arise in embryonic development.  Over the past decade or so, scientists in Japan have been studying germ cell development in mice.  It turns out that oocytes develop in the ovaries, and sperm in the testes, from more primitive germ cells called primordial germ cells, or PGCs for short.  It further turns out that mouse embryonic stem cells can be coaxed to develop into PGCs in the laboratory by applying a single protein, called bone morphogenic protein 4, at just the right time.  Once the scientists had found this out, they wanted to know whether the PGCs they had developed in the lab were for real.  The “proof of the pudding” in this case is to show that the PGCs can develop into mature sperm or eggs.  This, they cannot do in the lab (at least not yet).   So they injected their PGCs into the sperm or ovaries of otherwise infertile male and female mice, respectively.  And, lo and behold, they not only got mature sperm and eggs, but those sperm and eggs were able to fertilize eggs or sperm (more conventionally obtained) in vitro to generate mouse embryos, which developed to full term mouse pups when implanted into the uterus of a female mouse.

Now, initially, they started with mouse embryonic stem cells, obtained from an actual embryo (a process likely, at least, to destroy the embryo).  But they got the same results when they started with skin cells from mature mice and “reprogrammed” them into the “ethical” stem cells, induced pluripotent stem cells (iPSCs).  So, one could conceive of starting with a skin cell from a male and deriving an egg—a female gamete—from it through the iPSC route, while, conversely, sperm could be derived starting with skin cells from a female.  The possibilities, reports Nature, led the researchers to be deluged with inquiries from infertile couples, as well as from gays and lesbians interested in the ultimate prospects.

Well, the here to there—from mouse experiments to a new human assisted reproductive technology (ART)—is far from straightforward.  The Nature report lays out some of the issues:

  • Mice are not people (i.e., humans—they say “humans,” I say “people”), and in a very real sense, getting the same results in humans means going back to the beginning.  There is no guarantee that the step(s) from human pluripotent cells to human PGCs is as simple as it turns out to be for mice.
  • The scientists have not figured out, even for mice, how to get mature gametes from PGCs without implantation into ovaries or testes—kind of a critical step.
  • A next step would be to try to repeat the same thing in monkeys.  The scientists have gotten monkey embryos, and think that it will take another 5-10 years to repeat the work in monkeys.  It is assumed that going from monkeys to humans will only require “small tweaks,” because we’re both (humans and monkeys) primates, after all, and humans are biologically much closer to monkeys than to mice, but how easily monkey results would be translated to man remains to be determined.
  • Oh, one other thing—in the mice, the pups born from the stem-cell-derived PGCs→germ cells appear normal, but their offspring are not; their PGCs often produce fragile, abnormal eggs that give rise less frequently to normal third-generation offspring.  Translation: it’s conceivable that your kids by this method might turn out OK, but no guarantees about the grandkids.

This is an example of new science raising ethical concerns that are not urgent today, but can creep up on us eventually if neglected while the technical work proceeds.  We can bet the work will proceed.  There is no guarantee it will give rise to a viable human ART.  But a few thoughts on the ethics:

  1. The initial work in mice does not appear to be unethical at all—certainly not in methods, and apparently not in intent—the researchers were trying to understand biology, and they say they are not trying to exploit it.
  2. Similarly, I would not condemn similar studies in primates, but I would ask, “why do we need to know?”  If the only answer is, “so we can do this in man,” then I would challenge the ethics of the aims of the research.
  3. iPSCs may be ethically-derived stem cells, but that does not mean that they do not raise ethical issues.  (I have seen this point raised by scientists in the general press—for example, in a Scientific American article a couple of years ago—but I don’t have the reference at hand.)
  4. We should recall that iPSCs are not a panacea.
  5. An obvious ethical objection to an eventual attempt to apply this work to humans is that the risks to the children to be born cannot be clearly estimated or fully understood, and therefore neither described in informed consent nor minimized.  A response to this would be to propose extensive studies in monkeys, with observation of multiple generations, and use of preimplantation diagnostic techniques (genetic and otherwise) to select only those human embryos from IVF that are determined to be normal or to have the best chance of being born healthy.   This line of objection mirrors the line taken by Paul Ramsey against IVF in the 1970’s—there was risk of unacceptable harm to the intended offspring—but the rejection of moral status to the unborn plus the birth of a healthy Louise Brown (“the first test tube baby”) in 1978 together were taken to refute the objection, and IVF is common today, with many live births that are entirely normal as far as we know.  In this case, I’d tend to argue for the moral status of the embryo, and against the notion that we could ever really have sufficient evidence of the safety of the procedure for the offspring or their descendants.   It may be an argument I get the opportunity to make in my lifetime.  Or not—we will see.
  6. Turning this line of research into a new human ART would be another method of turning children into manufactured products instead of begotten results of the union of two parents.  I would argue that this point would be sufficient to proscribe the approach even in the context of a faithful, monogamous, traditional, Christian marriage beset by infertility.
  7. Some of the permutations of the approach that may be envisioned raise the objections about confusion of parentage that have been raised against human cloning and some other approaches to ART.
  8. And finally, and of course, the ultimate argument against applying this approach to people is that we ought to take a more “essentialist” line of human nature, and the created human order, and recognize the natural order of begetting children as erecting boundaries that must not be tested, much less encroached or crossed.  But, also of course, you have to believe in God to think that; it won’t fly with a naturalist.

Again we are on ground where we ought to fear to tread, and which should prompt us to say, quickly and without reservation, “we shall not.”

Paying for oocyte donation—California’s governor vetoes AB 926

On July 18, I wrote at length on this blog about AB 926, which had passed both houses of California’s legislature.  I was pleased to learn that California’s Governor Jerry Brown vetoed it on August 13.  Governor Brown, a progressive Democrat, can hardly be considered a pro-life conservative.

He based his reasoning on the issues of informed consent that I (and others) have described.  In my opinion, the key graph of his veto message is:

“In medical procedures of this kind, genuinely informed consent is difficult because the long-term risks are not adequately known.  Putting thousands of dollars on the table only compounds the problem.”

This of course keeps the reasoning fully focused on autonomy, and does not address the other major moral issues at stake.  But the governor’s decision is still the correct one, and wise.  At a minimum, it slows the freight train a bit.

You can read the entire concise veto message here.

Paying for oocyte donation—update from California

A number of concerned groups in California are encouraging citizens to urge Governor Jerry Brown to veto AB 926, which has passed both houses of the state legislature.   AB 926 would repeal a provision in the California Health and Safety Code that prohibits compensating women who donate their oocytes (eggs) for research purposes.   Wesley Smith has blogged against it, arguing that it would “permit Big Biotech to buy eggs from poor women to conduct human cloning and other experiments.”  One Leah Campbell, a past egg donor and author of a book entitled Single Infertile Female and an eponymous blog and website, writes in the San Diego Union-Tribune that AB926 “aims to turn women’s bodies and ovaries into an assembly line.”

What is going on?  It merits some unwinding.

In 2004, California passed Proposition 71, which established and provided $3 billion in bond funding for the California Institute for Regenerative Medicine (CIRM), to support basic and translational stem cell research.  The proposition explicitly cited human embryonic stem cell research as a major priority.  (In fairness, CIRM funds all things stem-cell, including somatic, or “adult,” stem cell research, and research with induced pluripotential cells [iPSC’s].)

As the California Senate’s analysis of the bill (available here) points out, at the request of the CIRM the Institute of Medicine (IOM) issued a 2007 report assessing the medical risks of oocyte donation for research.  Those risks included ovarian hyperstimulation syndrome (OHSS) which can have serious medical consequences in 1-2 of every 1000 stimulation cycles; risks of the procedures involved; psychological risks; and unknown but potential increased risk of some cancers.  The IOM pointed out that the stimulatory treatments needed for oocyte donation, when used in fertility treatments, are largely self-regulated by the medical specialty society involved, the American Society of Reproductive Medicine (ASRM), and the associated Society for Assisted Reproductive Technology.  Further, there is no ongoing registry of oocyte donors in place to observe women systematically, over time, for medical outcomes.  (This in the age of “evidence-based medicine.”)

Accordingly, in California law: “No human oocyte or embryo shall be acquired, sold, offered for sale, received, or otherwise transferred for valuable consideration for the purposes of medical research or development of medical therapies. For purposes of this section, ‘valuable consideration’ does not include reasonable payment for the removal, processing, disposal, preservation, quality control, and storage of oocytes or embryos” (Section 125350 of the California Health and Safety Code).  AB 926 would not change that part of the law.

However, in accordance with the sorts of concerns identified by the IOM, California law has prohibited paying egg donors more than the actual direct costs of the procedures (the “removal, processing, etc.”).  That is, women should not be charged for the medical and research procedures involved, but they shouldn’t be paid extra for their time and trouble, out of concern that such extra payment would constitute an unacceptable inducement to donate, and amount to impermissible exploitation.  This is what Ms. Campbell (and Mr. Smith, and to be candid, I) am concerned about.

Now, AB would repeal this specific prohibition, and allow this extra compensation of women who donate their eggs for research.  There are a couple of wrinkles:

First, as noted, the language prohibiting payment for the oocytes per se (or for an embryo) would not change, and new wording is provided to put a fine point on that.

Second, the bill tries to distinguish between donation specifically for research and donation for infertility treatment.  How?  To begin with, the rationale for the bill is that we already accept compensation for subjects of medical research, particularly for early clinical trials of experimental drugs given to healthy volunteers.  Such compensation can reach well into four figures per study, leading the phenomenon of the “professional research subject” who serially volunteers for these studies and tries to make a living off the compensation for participating.  Such compensation is for the subject’s time and inconvenience, and the consent form usually says so in so many words.  This is standard practice in research ethics, and there is a substantial body of literature (and ongoing debate) around the merits or harms associated with this practice.  The argument for AB 926 is that it would just treat women who donate their eggs for research like other research volunteers.  Further, without the compensation, people won’t volunteer.  (That is a safe assumption, based on the experience with drug studies in healthy volunteers.)  And, since much of the research is sponsored by industry, Wesley Smith is, in a sense, correct:  industry is not paying for the eggs proper, but they are paying for enhanced research participation.  I leave it to you to judge whether this is a distinction without a difference.

How much compensation is too much?  That is for Independent Review Boards (IRBs) to decide.  AB 926 affirms that the IRB must make this judgment in the case of compensation for women who donate their eggs for research.

But what about women who donate eggs for infertility treatment?  AB 926 tries not to be about them.  But if there are “extra” eggs—eggs that an infertile woman deems, with her doctor, she doesn’t need for her attempts to have a baby—then, if the clinic harvesting the eggs belongs to the Society for Assisted Reproductive Technology, then the IRB “shall disregard” the matter of compensation.

Got that?  The further wrinkle is that, according the California Senate’s analysis and the IOM report, while ASRM endorsed this sort of compensation for women who donate eggs for infertility treatment, it said that “total payments to donors in excess of $5000 require justification, and sums above $10,000 are not appropriate.”  Yet it is common knowledge that these payments can be much greater than that.  But in that case, AB 926 tells IRBs, “never you mind.”

Ms. Campbell (see the Union-Tribune link above) wrote that the aftermath of her egg donation included severe pain from endometriosis related to the ovarian stimulation, and, in a cruel irony, now she is herself infertile.  Her story reminds one of “Eggsploitation.”

So what to say of all this?

  • A decade after Prop 71, the commodification of the egg donation process, in the name of supporting research with created embryos, is a reality.
  • If I were on an IRB evaluating a proposal, it would be a lively meeting:
    • The egg donation is likely primae facie unethical because it supports the fundamentally unethical act to create or destroy human embryos solely for research purposes;
    • Compensation to the donor would have to at least fall within the ASRM dollar limits as described above; higher amounts should be viewed as an unacceptable inducement;
    • The required description of risks to the donor in the consent form must make the risks of severe complications of OHSS, and the lack of data on long-term risks, starkly evident;
    • I would argue strenuously that two basic requirements of IRB approval of the research—that risks are minimized and that they are commensurate with the benefits of the research—could never be met.

This one had flown under my radar, and I now need to send a letter to the governor.

Emergent Dualism and the Sanctity of Human Life

My wife and I spent May 10-11 at the annual conference of Biola’s Center for Christian Thought (CCT), where the theme for 2012-2013 has been “Neuroscience and the Soul.”  The plenary talks are not all on the web, yet, although some are on Facebook, but a number of discussions on the general topic may be accessed here.  I encourage readers of this blog to spend some time knocking around the CCT website.

The weekend (though perhaps not the year, more broadly) didn’t have much neuroscience in it.  Most of the time was spent talking about philosophical and theological anthropology—in particular, what is the soul?  As I have previously written on this blog, I am most attracted to a “Thomistic substance dualism” (after Thomas Aquinas) of the sort advocated by J.P. Moreland of Biola, who argues that the “soul” is a simple (it doesn’t have parts) nonmaterial substantial entity that contains all the ultimate capacities of an organism and which is intimately involved in directing that organism’s development and expression of those capacities.  The word “ultimate” is critical here, because, as we all know, not all members of the human race realize all capacities at all times.  Moreland’s development shores up some shortcomings of Aquinas’s dualism (e.g., the notion that human embryos acquire souls at either 40 [males] or 80 [females] days of prenatal development), while attempting to retain its merits.  It, and other approaches that reject equating mind with brain function, appeal to certain Cartesian intuitions, like those of self-awareness, the sense of “what it is like” to have an inward experience, and others.  The philosophers call these “qualia” of mental events, which make them non-identical with physical/biologic events.  At the same time, Moreland and those of like mind reject the radical Cartesian distinction between mind and body in favor of a more wholistic, as it were, view of what the soul is and does.

Now, this fits nicely with the biblical notion of the image of God, even if one rejects Moreland’s view that the image is what man is, not just what man does (tend the earth), or the relationship between man and God, or the “status and standard” of man relative to God, creation, and the ultimate perfection man.  But I would argue that Moreland’s Thomistic substance dualism is not just faith-based, but also supported by formidable philosophic arguments and accessible on the terms of general revelation.   As such, I think it provides the strongest support available for the sanctity of individual and collective human life.  One sees this in arguments most commonly employed (perhaps not surprisingly) by Roman Catholic thinkers like Robert George; to wit, “humans are the kind or sort of being that….”

Two criticisms of Moreland’s view are:

  1. It amounts to vitalism, an otiose idea long-ago relegated to the biology’s scrap heap of history.   Moreland’s rejoinder to this is to claim that bad, old-fashioned vitalism was too crude, and that a more modern view, “organicism,” is more promising.  (I can’t carry on about that, yet.)
  2. Evolution is irreconcilable with the Thomist view of the soul, because the latter requires that genus and species not be degreed properties, but be in a real sense, immutable.  I agree that the Thomist view pushes one there, and I think that (along with Moreland, I believe), as these critics claim, the Thomist view requires one to accept that God is progressively active in creation.  But these points are said to be unacceptable because of the science of human evolution.

So, as an alternative, some philosophers who remain sympathetic to the idea that mental phenomena are not reducible to physical processes, and in fact are different in ways that cannot be fully explained by appealing to physical processes, nonetheless inescapably depend on those processes and “emerge” from them.  However, they would hold, what is emergent is not just mental properties but an actual, and in a meaningful sense, substantial self.  So they are dualists about human nature—even, in a sense, “substance dualists,” but they are less ready to allow that the human soul might exist independently of bodily life and processes—particularly those of the brain.

Now, there is more to be said about this than I can say, here or elsewhere, but it seems to me that the appeal to a “degreed” nature of life or consciousness disallows categorical distinctions of moral status between individual people, or people in general, and other beings.  (It seems to me that the emergent dualist also conceives “soul” as too readily identified with higher mental properties than the Thomist view would insist on.)  It risks making “personhood,” or “dignity” or moral status a degreed property.  Should we be more concerned about an anencephalic baby, or a fetus with Down syndrome, than a fully-endowed and functioning gorilla, and if so, why?  Should we be troubled about creating a human/non-human hybrid, and if so, why?  Would a super-intelligent robot, if there could be such a thing, potentially be a rival of “natural” humans in competing claims for concern?

I tried this out on a prominent Christian emergent dualist at the conference, and he quickly dismissed my objections.  To be fair, I hit him with a “drive by” on the coffee break, but as it happened, when I pushed, he responded, in effect, we can’t base all our moral appeals on rational argument.  Sometimes we have to just demonstrate the truth of the gospel, and show people the choice between worldviews and their consequences, and ask them what do they really prefer?  And, as unfairly as this brief post may be posing the issues, that kind of rejoinder worries me.

Ultimately, some appeal to a “givenness” of human nature is necessary to defend boundaries in bioethics.  We might indeed appeal to the naturalist by counseling caution—evolution has, over millions of years, presented us with ourselves, including our common intuitions—and we ought to have a “default” position of “no-go” on the most “out there” ideas.  We might indeed present a “two views” picture, and ask people to choose what kind of world they really want and what sort of people they ought to be.  We might argue, as I take the German philosopher Jürgen Habermas to argue, that the interplay of human autonomy, human language, and human social relationships lead us to conclude that some technological interventions would tend fundamentally to destroy who we are in community, and so ought to be avoided.  But I think it’s harder to identify, on emergent dualist grounds, what if any specific maneuvers ought to be proscribed with “thou shalt not,” or words to that effect.

The emergent dualists might be right.  (I tend to agree with Moreland that the position is unstable, tending toward either his dualism on the one hand or functionalism on the other.)  If so, we should, as the philosopher I challenged told me, follow the inquiry where it leads.  (One approach that could be called into question is Francis Schaeffer’s approach of asking whether one can live with the consequences of one’s philosophy.)  But my efforts, at least, are still awfully preliminary.

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.