The Assisted Reproductive Technologies
Professor Gareth Jones is a committed Christian who has spent considerable time pondering the ethics of birth technologies froma Christian perspective. What do the various procedures involve and what are the questions we should be asking?
On 25 July 1998, Louise Brown was 20 years old. While she was the first child born via in vitro fertilisation (IVF), she was not alone for long. Since those early days a further 300,000 children have been conceived in the same way, using a variety of techniques ranging from conventional IVF through to the use of donor gametes, transfer of the embryo into a surrogate, and preimplantation genetic screening of in vitro embryos.
In 1987 when I wrote my book Manufacturing Humans (Inter Varsity Press), I spelled out 13 technological ways of producing a child, all of which still apply, although conventional IVF has now been extended by the development of a variety of increasingly sophisticated procedures.
IVF procedures include the conventional technique by itself, as well as sperm, ovum or embryo donation; surrogate motherhood together with IVF; surrogate motherhood together with IVF and sperm or ovum donation; and surrogate motherhood together with IVF and ovum and sperm donation. Some of these procedures result in the child having as many as five parents.
Gamete intrafallopian transfer (GIFT), in which sperm and up to three eggs are mixed together and transferred to one or both of a woman's uterine tubes, is generally seen as part of this panoply of techniques. However, it is not strictly IVF, since fertilisation occurs in the woman's body and not in the laboratory.
Over the years there has been an enormous amount of discussion in the ethics literature about the success rates of IVF. While figures for this vary very considerably from one clinic to another, let alone from one country to another, it is worth quoting some figures. These are the British ones published by the Human Fertilisation and Embryology Authority in its sixth annual report in 1997. In the 15 months up to 31 March 1996, there were 36,994 IVF cycles started in 26,967 patients, and of these 30,354 reached embryo transfer. There were 6,827 clinical pregnancies (18.5%), and 5,542 live births (15.0%).
One of the well known features of IVF is the high incidence of multiple births, due to the transfer of more than one embryo. The live birth rate (as a percentage of treatment cycles) rises from 6.8% for one embryo transferred to 21.4% for three. However, the multiple birth rate (as a percentage of live births) also rises - from 4.0% for one embryo to 32.9% for three. In these figures three embryos (the maximum number allowed in the UK) were utilised in 55% of the treatment cycles.
But why introduce IVF in the first place? Why not leave nature to take its course? Initially IVF was introduced to treat infertility, since 10-15% of couples have infertility problems.
IVF involves fertilisation taking place in the laboratory, and consequently embryos are fertilised outside the body. Once this is possible, embryos can be investigated and experimented on. Indeed, in order to develop IVF as a technique, and subsequently to increase its efficiency, research on embryos has been essential.
This is still the case and it immediately raises the question of the status of embryos. Should embryos be treated like this, or should their lives be sacrosanct?
A great deal of Christian debate has been focused on this question, with some concluding that IVF is ethically unacceptable. In spite of this, most Christians seem willing to accept conventional IVF, albeit reluctantly in some instances.
Even though IVF entered clinical practice as a way around infertility, its uses soon expanded to encompass couples with borderline infertility, to enable older and even post-menopausal women to conceive, as well as to provide lesbian and gay couples with children. This is hardly surprising, since a technique such as this can be used in innumerable ways, depending on the social and moral environment in which it is practised. Also, as we have already seen, it can be used in conjunction with the donation of gametes, and with various forms of surrogacy.
Even the conventional form of IVF is not simple. The woman must be hormonally stimulated, causing her to superovulate and produce a few (sometimes many) eggs per cycle. This makes a number of eggs available for fertilisation, so that a number of embryos (only up to three are allowed in certain countries) are inserted in the woman's uterus in the current cycle, with the remaining embryos being frozen and inserted - if required - in subsequent cycles.
As we have seen, the attraction of this approach is that the chances of the woman becoming pregnant increase when two or three embryos are implanted, thereby saving the woman from having to undergo repeat procedures to obtain eggs in later cycles. But an inevitable consequence of this approach is the existence of spare or surplus embryos.
If not required by the originating couple, these can be: i) donated to another couple; ii) used for research purposes; or iii) dispensed with. Such decisions have become inevitable in this new world of controlled reproduction. Can these quandaries be justified even if the technologies enable couples to have their own children?
What can be accomplished technologically and what we should or should not do are closely intertwined. The absence of simple answers means that very demanding decisions have to be made.
Development of Techniques
IVF has spawned numerous other techniques initially referred to as the new reproductive technologies, then as the artificial reproductive technologies, and now as the assisted reproductive technologies (ART). This latter term focuses more on the assistance given to fertilisation than on the artificiality of the procedure, since some of the recent developments seek to help what should occur naturally.
A technique used increasingly these days is intracytoplasmic sperm injection (ICSI), which is appropriate where the male partner has very few sperm. With ICSI, a single sperm is injected directly into the egg previously retrieved from the woman. If the egg fertilises, it can be transferred to the uterus in the usual way.
This is now viewed as the treatment of choice for severe male infertility. However, is its success being bought at a price, since the spermatozoa being used may be defective? Will this lead to an increased incidence of health problems in the resulting children?
Different studies have come up with different results, including the possibility of an increased incidence of congenital abnormalities, and an increased risk (17%) of mild developmental delays at 1 year (compared with 2% in children conceived by conventional IVF).
ICSI is beginning to replace donor insemination and adoption, since pregnancies can be achieved despite severe impairments in semen quality, and with very small numbers of spermatozoa. When ICSI is used for severe male infertility, pregnancy rates of up to 52% can be achieved, with ongoing pregnancy and live delivery rates as high as 37% per IVF cycle attempt.
Is this a way forward for those Christians who are unhappy about employing donor insemination? Will this very sophisticated form of technology actually decrease ethical dilemmas for Christians?
Preimplantation genetic diagnosis (PGD) is a technique used to detect whether an embryo created in vitro is carrying a genetic defect, which will give rise to a serious inherited disorder. It can also be used to determine the sex of an embryo where a family is at risk of passing on a serious sex-linked disorder, such as Duchenne's muscular dystrophy, to a male child. This process is repeated until a 'healthy' embryo is obtained; 'unhealthy' embryos are discarded. Should embryos with serious genetic defects be discarded?
Currently unproven techniques include the use of spermatids in ICSI. Spermatids are immature sperm, and few babies have been born as a result of this technique. This is a research technique, although it holds out hope where the male partner has no sperm.
The use of a frozen egg in a successful live birth was reported as long ago as 1986. However, it has not been possible to repeat the event, and the cryopreservation of eggs for routine clinical purposes is not yet a practical proposition.
While ART procedures are generally considered to present no risks to the woman, there may be exceptions. Increased rates of preeclampsia, diabetes mellitus, bleeding and anaemia have been recorded, while hormonal stimulation during ART may increase the risk of ovarian cancer.
At a purely technological level, the successes of these techniques are striking, and we should not seek to run away from them simply because they are surrounded by a host of ethical, social and spiritual queries.
The Human Face of IVF
June and Nick are healthy in every respect, except for June's infertility caused by blockage of her uterine tubes. They entered an IVF programme where eight embryos were produced, and six have been used. Two children have been born. They do not want any more children and so have decided that the two remaining embryos will be discarded.
In this instance, the creation of human lives is coupled with the possible manipulation of other lives - those of embryos. The power over human life is power over creation and destruction, since the continued development of some embryos into fetuses and children may not have taken place without the likely destruction of other embryos.
With children and adults it is not normally ethical to choose between individuals in this manner. The difference here is that all the embryos were created with the intention of giving rise to ongoing human lives: the couple wanted children. Inevitably, some of the embryos are being sacrificed so that others will be provided with a better chance of developing further. Choices are being made.
The legitimacy of this choice depends on a variety of theological and ethical considerations. We have moved some distance from natural reproduction, and human decision-making is now dominant all along the way. However, this is occurring within a pathological context; something has gone wrong, and the procedures are therapeutic ones.
When a couple wants a child naturally, their concern is with the child that finally emerges from the uterus, not with the number of embryos that may be miscarried in the process. For most couples spontaneous abortions are a common accompaniment of the birth of children, and while this does not justify the wholesale destruction of embryos in the laboratory, it reminds us that to concentrate our moral vision solely on embryos may prove misleading.
When choices have to be made, do children and adults matter more than embryos? That is the question we all have to answer.
Janet and Paul have one child with cystic fibrosis, and both are worried about the prospects of another child with this disease. They are informed that the embryo can be genetically tested before it has a chance to implant in the uterus (by PGD). If the embryo has the gene for cystic fibrosis, it will be discarded and the same procedure will be carried out on a second embryo.
The purpose of this procedure is to ensure that Janet and Paul do not have a child with cystic fibrosis. But this entails a choice, between a defective embryo and a (hopefully) healthy child.
Should a defective embryo (with a serious medical condition) ever be implanted in a woman's uterus for further development? To proceed with such an embryo would ensure that a child with a serious ailment is brought into the world, when an alternative is available. In my view, doing this would amount to a form of genetic predestination, since it is known that this embryo will give rise to a child with a specific, lethal ailment (we are talking here about very serious conditions).
To ignore what is definitively known about the future of a specific individual is to ignore an important aspect of that individual's well-being. This can only be justified if the value of a particular embryo is regarded as being greater than that of the resulting child, and if the quality of the resulting child's health is ignored. This is an extremely difficult area, in which there are no slick right/wrong answers.
Christians should not feel they have to accept whatever turns up in the genetic 'lottery'. Most Christians utilise medical treatment to alleviate or cure illnesses (even when these have a genetic basis), suggesting they do not accept the inevitability of genetic predisposition. If this is correct, should embryos with destructive genetic predispositions be preserved at all costs? Or should we value more highly the human-in-the-making, the human who will be, the family of that individual, and the relationships of all involved?
When confronted by a person with a disability, that person is to be treated as someone imaged in God's likeness, since the essential characteristics of God are present even when the disability is considerable. However, when discussing a very early embryo, are we discussing such a person?
As God's stewards do we have a mandate to ensure that a very early damaged embryo develops into a damaged person? I am far from convinced that we have such a mandate.
Profoundly far-reaching choices are being made, but these can only be circumvented by living in ignorance, and by rejecting avenues opened up by biomedical knowledge. A convincing Christian rationale must always be provided when people are seen to be doing this.
Where has ART brought us?
We live in a world unknown to most of our parents and certainly to our grandparents, and there is no turning back. As our world has changed, so have we. Our expectations have changed, since we expect women to conceive when they want to, and if this does not occur we expect there will be a means around the problem.
Technology can solve technological problems, but at what price has this been accomplished? If children can be produced by technological means, does this alter our view of children?
Do we love these technologically produced children in the same way we love naturally produced children? I believe we do (or we can do), but some Christians disagree.
For many today the dazzling successes of modern medical technology are dwarfed by the arrogance of biomedical scientists and medical practitioners: given time, everything can be accomplished; who needs God when human health depends upon human technological expertise? Individuals are brought into existence by technological means; they are made rather than begotten; they have become the playthings of a scientific elite. This may be putting things rather strongly, and yet it should not be completely overlooked.
Deep within all the ARTs is the dominant element of human control, with its bringing together of human intervention and a laboratory environment. For some this is dehumanising, on the grounds that baby making and love making have been separated.
For others the planning is supremely human, especially since an obstacle to marital and human fulfilment has been overcome. In order to do this, there has been a movement away from the physical and sexual in human reproduction, and yet we accept this intrusion of the artificial and technological in many other areas of our lives, including other medical areas.
IVF is quite often a failure. Some couples who might be expected to benefit from it fail to do so. The successes of IVF, therefore, have to be balanced against the failures: those who are disappointed and frustrated at having their last hope of a child dashed. However wonderful it has proved for some couples, IVF is not to be viewed as a panacea for solving all our problems.
In my view, conventional IVF is ethically acceptable because it allows a couple in a stable relationship to have a child derived from their own bodies. But this must be seen within the context of family love and commitment. If it is used to allow anyone to have a child, regardless of family ties and long-term obligations, it becomes a threat to family life.
For infertile Christian couples, the matter needs to be prayed about, and God's will needs to be sought for each individual couple. The goal for all Christian couples, regardless of their fertility or infertility, should be the service of their fellow human beings. We need to ask what God would have of us, and how we might best serve Christ who gave himself in the service of others.
The desire for a child is not to be shunned. This does not mean it is to be satisfied regardless of marriage and family obligations, any more than other deep desires are to be automatically fulfilled. Nevertheless, the desires of the infertile for a child are to be taken very seriously both by individual Christians and by the church.
Gareth Jones is Professor and Head of the Department of Anatomy and Structural Biology at the University of Otago. He has a long-standing interest in ethical issues surrounding the reproductive technologies. He is a member of Dunedin City Baptist Church.