Assisted Conception: Ethical and Social Problems

Author: Fisher


Paper presented to the Life Conference Leamington Spa, 8.10.94

We are presently witnesses to a reproductive revolution potentially more significant than industrialization, nuclear power or the computer. Already fertilization, the laboratory production of test-tube babies, has become fairly commonplace, with dozens of IVF programmes in most Western countries and perhaps 100,0000 test-tube babies born around the world since Louise Brown in 1978. A whole range of other things are already possible or will be in the near future in the realm of the new reproductive technologies.

The crucial aspect of this reproductive revolution has been the ability to separate genetic (blood) parenting from gestational (carrier) parenting and both or either of these from social (nurture) parenting. All these functions can now be performed by different people. And the person who brings it all about—a biotechnologist, very possibly a veterinarian—will be a different person again. Various degrees of technological intervention are possible: from the simpler procedures such as Artificial Insemination, to the more complex but increasingly routine IVF procedures, to the increasingly sophisticated forms of genetic engineering. [I bracket out of consideration here and in the rest of my paper the range of assistance in conception which does not require disintegration of this kind: sex education; natural family planning with a view to maximizing conception; microsurgery and other treatment aimed at correcting defects in the reproductive organs; fertility drugs; the relocation of a ripe ovum from the ovary to the other side of a fallopian tube blockage.]

All these things can be done either for altruistic or commercial reasons: recently a Virginia clinic which prides itself on being 'the McDonalds of medicine', offered British women donor eggs on demand and the rest of the IVF kit and caboodle for a mere 10-15,000 pounds plus expenses of getting and living there (the donors get about 6,000 pounds for their eggs). And all these procedures can be either voluntary or non-voluntary or somewhere in-between, as where, for instance, women are given preferential healthcare if they agree to donate eggs. By separating genetic parenting from gestational and social parenting various new family relationships also become possible or at least easier: homosexual couples, for instance, can now commission others to provide whatever they cannot, with a view to their receiving a child to bring up.

A crucial aspect of this revolution, as I have said, is the separation—I would say more pejoratively, the disintegration—of genetic parenting from the rest of parenting, from carrying and bringing up the child. Of course this has always occurred through adoption, though adoption is rarely planned from the outset. Now, from the outset, we can arrange matters so that one or more of the genetic parents are different from the woman who will carry the child or the couple who will bring her up. These people may or may not be related to each other. Various kinds of third party donors can be introduced: an ovum donor, a sperm donor, embryo donors. There is a big campaign at the moment here in Britain to get more egg donors. The donor of these sperm, eggs or embryos can be alive or dead, as where sperm or eggs are kept frozen from some now-deceased donor, or where eggs are extracted from an aborted foetus or recently deceased woman. With the advent of cloning or parthenogenesis, only one genetic parent will be necessary; with chimeras it will be possible for one child to have several genetic parents.

'Designer babies' are already with us. Until recently the only way to affect the genetic make-up of your child was to choose your partner carefully. Nowadays we can choose someone just for breeding purposes: California, for instance, boasts a Nobel prize winners' sperm bank where a woman can buy genius sperm in the home of producing a genius child. (There is no evidence it works.) All that is a fairly ham-fisted way of designing babies.

We have a more effective way: we can test the babies we already have, either while they are in the laboratory petri dish or in the womb, to see if they have the characteristics we want or don't want. If they have characteristic we want, we can transfer them to the womb or let them go to term. If they don't we can flush them down the sink or abort them. We already commonly do this for certain handicaps which are regarded as so horrible that the children concerned are better off dead. The list of those handicaps is growing, partly as a result of increased technical capacity to identify more and more of them, more and more accurately; and partly as a result of the line moving as to which handicaps are incompatible with worthwhile existence. Sex is now such a handicap in some countries and in some families. The human genome project opens up possibility of being able to identify a great many more characteristics which are partly or wholly genetically determined: e.g. genes associated with skin, eye or hair colour, with higher risk of heart disease, with certain personality characteristics such as intelligence, homosexuality or aggressiveness. And the more of these things we can test for, the more undesirables we can abort.

The next generation of designer babies will be one designed directly, by introducing preferred genes. More and more sophisticated genetic engineering will be possible in our life time. Oxford University philosopher Jonathan Glover looks forward to the day when we will pick the eye colour and intelligence of our children from the reproductive supermarket shelf; American theologian Joseph Fletcher to the day when we can design role-related people (e.g. people with extra lungs, or limbs, to help with certain jobs). The potential for eugenics, breeding in and breeding out certain desired or undesired characteristics in whole populations, will grow enormously.

While screening followed by abortion will be the most common response to genetic handicap, the new reproductive technologies do open up exciting new possibilities in the area of gene therapy. Leaving aside the complex area of germ-line therapy, it will be possible and often ethically permissible, to correct certain genetic handicaps very early in life. [Whether much research and development will go into genuine gene therapy is yet to be seen.]

Less attractive is the possibility of animal-human hybrids. Cross- species fertilization and introduction of parts of genomes is already common in animals as in the case of the super-rat and the super-pig. Some animal-human crossing also occurs, as when human sperm are tested for their fertility by crossing them with hamsters (here in England) or rats (in Australia).

And all these technologies open up new sources for laboratory embryos and foetal tissues, which might be used for experimentation or for spare parts.

So far I have reviewed only the ways in which we can now exploit a disintegration of genetic parenting from the rest of parenting. But we can now also separate out the gestational parenting, i.e. who carries the child. Again, this womb donor or surrogate mother may or may not be related to the other parents involved. She might even be near-dead, as in the Edinburgh proposal to use permanently comatose women as 'incubators'. Or she might be a post-menopausal woman: the new technologies have given women babies in their late fifties and early sixties, but they might well soon allow women to carry babies and give birth well into their seventies and eighties... Not of course that the carrier has to be a woman at all. It could be a man, and the technology for that would not be very complex. Animal wombs might be used in the future to carry human children (we've already tried using a sheep's womb in Australia) or even machines ('ectogenesis'). But for now we are stuck with women, alive of near dead, young or old.

On the face of it, some at least of these assisted reproduction technologies are technologies: after all, they give people babies. And not just any people: suffering, infertile people, people with a very natural and reasonable expectation of completing their marriage by giving life and love to a new human person. As pro-lifers we have sympathy and admiration for such a couple as they swim against the increasingly anti-life, anti-child, anti-family tide in our community. And so we would never judge those involved: they are often so desperate or so full of good will. The fact is we have an infertility epidemic in this country, with perhaps one in ten couples having trouble having a child. And adopting has become well nigh impossible. For many people these technologies offer the last hope. And as a useful spin-off we are likely to learn a great deal about reproduction along the way, including possible future drugs and cures.

Many of these advantages of the new reproductive technologies are immediately attractive to everybody; hence most of these developments have been met with uncritical acclaim by the healthcare professions, the media, government, the general population. With a few of the more bizarre proposals there has been some disquiet (the 'yuk factor'), but it does not usually last for long and rarely holds up the real research agenda. In most respects, however, these technologies have great audience appeal. I too was at first attracted by these technologies, especially 'IVF in the simple case'; and I wished the objections would be answered, the problems solved, that the difficulties would go away. The publication of a number of important studies of the ethics of IVF technologies, including one by my own Church, and my researches for my book on IVF including interviews with IVF doctors and couples, and a great deal of reading in those most inaccessible of places, the medical, legal and philosophical journals, led me to change my mind.

But I still find myself often asked by pro-lifers: what's wrong with IVF in the simple case?

IVF in simple case means this: a married couple have tried everything else in order to have a child; eggs and sperm are taken from them as safely as possible and in the minimum quantities necessary; only as many embryos are created as are intended for placing into the woman's womb, with the genuine hope that these embryos will implant and come to birth; no abortion is planned, even if things go wrong along the way; and there are no morally complicating third parties involved, except of course the technologists. Which is all very well. But let's now consider IVF as it's actually practised. First, the couple may or may not have tried everything else. Increasingly today it is tried many other therapies such as NFP, microsurgery or GIFT. So the couple join the programme. The woman is given a fertility drug to ensure she produces several nearly ripe eggs at once and these are collected; the man is sent at the appropriate time to a cubicle to produce some sperm; and then several embryos are created at once in the laboratory. Several, notice. More by far are created than children are wanted. The healthiest looking ones are chosen for transfer to the woman's womb; many others are discarded. Some are frozen with a view to using them later; but freeze-thawing kills many. Some are used for experimentation, which is always lethal.

The lucky ones are transferred to the womb. But multiple transfer greatly increases risk of miscarriage and premature birth, so they might well not survive. The pregnancy is carefully monitored so that if too many embryos have implanted and survived into the second trimester, 'selective termination' (i.e. abortion) might be performed on some of them. Genetic screening and abortion for handicap is also very much on the cards. But the luckiest ones come to term and survive the high neonatal death rate among IVF children, and go on to feature on the covers of women's magazines with their proud parents.

But most were not so lucky. Most died along the way. Not of course that all these deaths are intended; some of them may even be genuinely regretted. But these deaths intentionally risked. And the fact of the matter is: many hundreds of thousands of human beings have died so far in an effort to bring some to birth through IVF. IVF, as it's actually practised, even in Catholic hospitals, by Catholic doctors, for Catholic couples, is driven by an ethic of success at all costs; people want a baby and they do not want to inquire too closely into what deadly practices might be required. And deadly practices required.

But, you might say: it possible to imagine a more pro-life IVF protocol. Maybe... though I doubt that in the real world of contemporary medical science it would get very far. Modern healthcare is profoundly influenced by the technological imperative, the notion that if a thing can be done it should be. All scientific advances, however attained, and their applications are presumed to be self-justifying and any opposition is dismissed as backward. Medicine is also a deeply pragmatic activity; the "results are all that count" mentality dominates. If higher success rates and new discoveries can only be achieved at a high cost in terms of human life, risk to women and to society so be it; no scientist worth his Nobel prize willingly adopts a deliberately inefficient and less effective practice.

But let us imagine the pro-life IVF programme. We still have to face the question of how we get this technology. It does not drop from heaven. The imaginary 'pro-life' IVF programme gets its science from the much more lethal normal ones across the road.

Every embryo used for experimental purposes is destroyed; that's the law. Without directly killing or immorally risking the deaths of a great many human individuals in the research and development stage, and in the continuing experimentation to improve this technology, IVF could never have happened, or at least never so quickly or successfully. On that matter, at least, the would-be embryo experimenters have a point. And many more embryos are likely to be killed as scientists attempt more and more weird and wonderful things here and throughout the world. The IVF couple, even the pro-life, IVF-in-the-simple-case couple, benefit from this homicidal research. So do their doctors.

We do, of course, sometimes apply the results of immoral research: much of what we know about hypothermia, for instance, comes to us courtesy of some monstrous Nazi experiments, but the information is now used legitimately. Here we enter the complex moral maze of co-operation or complicity in evil, and I will not attempt to set out the principles today. Suffice it here to say that it is very much a matter of what one chooses, what one makes one's own purposes or the means to those purposes, and thus what one makes oneself. People can and often do co-operate in evils they do not approve of themselves; sometimes that is unavoidable; sometimes it is avoidable but permissible; and sometimes it is immoral and hypocritical. Even where one's co-operation is unintentional, one must consider seriously the ill-effects of so co-operating.

Perhaps we might consider an analogy. People now benefit from Nazi studies of hypothermia, though they probably would not want to be reminded of just how the medical profession has come by this information. We might be comfortable enough with people benefiting from that knowledge now, when those who apply the knowledge or benefit from it are all at more than arm's length from the experiments. But what would we have thought if at the very time when these monstrous lethal experiments were being carried out upon Jews and others, the same doctors were using this information to help patients who, while they might not have approved of the means of gathering the information, were all too pleased to benefit immediately from the latest discoveries? And what if their doing so helped to keep the whole dastardly experimental programme going?

Perhaps IVF-in-the-simple-case, pro-life IVF, is starting to look a little less pro-life to you.

When Aldous Huxley wrote his babies in bottles were the merest science fiction, a dream impossibly far in the future. Before he died he expressed confidence that "technically and ideologically we are still a long way from bottled babies". Well the technology which made it all possible marched forward much more quickly than he imagined possible. So did the ideology.

I would argue that without the abortion spiral of the late '60s and '70s, and its effects on social attitudes to early human life, this technology could never have happened. A generation ago people would have recoiled in horror at the very notion of using and abusing early human lives in the ways we now do almost as a matter of routine. And what softened up the public consciousness, what laid the blood red carpet along which the biotechnologists could pass with their test-tubes, was the abortion spiral. IVF and related technologies, however pro-life they might look on the face of it, are in this important respect a by-product of the abortion revolution.

Abortion proved the biggest boon to the revival of eugenics which suffered a short-term set-back as a result of certain disreputable practices in World War Two Germany. Nowadays it is assumed by many that the handicapped are better off dead, better off never born, or at least that we who have survived birth are better off if they are never born. This assumption is powerfully at work in many assisted reproduction programmes. And the group of those regarded as 'life undeserving of life' will keep growing as the genome project teaches us more and more.

The ideological revolution that makes IVF possible does not start or finish with the abortion revolution. Absolutely crucial is the post World War Two advent of the consumer society. The consumer mentality has profoundly affected the way children are viewed in our society. The me generation, and their successors the yuppies and dinkies, believe that we should want and have children only at the 'appropriate' time, if at all, in limited numbers, carefully spaced and genetically perfect. Children are one more consumer item to add to the satisfaction of their consumer parents. The rhetoric of IVF is replete with such talk, talk of ownership, quality control, demand and supply, take home baby rates, patents etc. The focus here is very much on needs or desires of the market (the would-be parents), and of the suppliers (the would-be experimenters), rather than on the children affected and the common good.

With these distortions of values, of ideologies, comes a profound distortion of relationships: young human beings are depersonalized, reduced to the status of commodities, manufactured and supplied (or experimented upon or quality controlled and destroyed) on demand. People are viewed as products. This leaves the test-tube baby is in a position of radical inequality, profound subordination, the parents and technologists who decide whether she will live or die. This kind of power is dangerous enough for anyone to have over anyone else; but it is all the more dangerous in a consumer society where the market rules. Hence the ease with which our society engages in what seems to many an extraordinary paradox: disposing as it does of so many children on the one hand, and engaging in an equally frenzied effort to create them on the other. The logic of the market.

We are witnessing in our day the production of a race of laboratory humans, second class and disposable. And in these new reproductive technologies we are being swept along by a dynamic of domination, exploitation and violence, however pro-life our sympathies might be. We are being swept along by the relentless assault upon human life and dignity characteristic of our violent times and being incorporated into structures and practices which are deeply corrupting our respect for human life. Assisted reproduction has become an integral part of that.

I will just flag here two other specifically pro-life worries that I have concerning IVF. First is the hidden agenda. Why are IVF scientists so fascinated with human embryos, especially when there are more efficient and effective ways of dealing with infertility? The psychology and sociology of scientists is complex and I will not explore it here; but I suspect that a principal driving force is the twentieth century dream of the perfect contraceptive. And for 'contraceptive' we should read 'contragestive'; RU486 is only the first on the scene of a whole range of do-it-yourself abortifacients which are likely to come onto the market in the next generation. A principal source of our information about how to stop embryos implanting in the womb and how to get wombs to reject them will be supposedly pro-baby IVF research.

Another specifically pro-life concern I have about these technologies is that they seek to plaster up the cracks left by a contralife society and medical profession, in particular the disastrous ineffectuality of public health programmes in this area, and the iatrogenic, doctor-caused infertility associated with decades of abuse of women's bodies in the search for sex on demand with no strings attached and for babies on demand. Without pretending that all infertility is associated with sexually transmitted disease, surgical sterilization, contraception and abortion, we must face fact that a great deal of what goes on by way of the new reproductive technologies is an attempt to deal with harms we have done to ourselves, harms only possible in a society which fails to respect human life and the human body as it should.

Just as in the abortion debate we pro-lifers do not restrict our attention to the unborn child, but demonstrate our compassion for all the living, so regarding the new reproductive technologies we should consider the women who are damaged. IVF is in fact not a very successful technology. The best programmes report success rates of around 15% and this rate seems to have plateauxed. Women can keep going back for cycle after cycle, but for most after a long series of highly intrusive procedures and a roller-coaster of emotions there will be no child at the end.

In the meantime, however, there are a range of serious risks. The high doses of fertility drugs come with a range of side-effects; patients have died after egg collection; there is a dramatically increased chance of multiple pregnancy, miscarriage, premature labour, ectopic pregnancy; and about half these women will have caesarean sections. We have not even begun to study the effects of things like post-menopausal pregnancies on women's bodies. But a powerful feminist case against these technologies has been made, especially in Australia: women's bodies are being used as living laboratories for prestigious but dangerous research largely by men who are content to further their own interests at the risk of replicating the tragedies of Thalidomide, the coil, breast implants and the like.

Evidence of serious psychological ill-effects of these procedures is now emerging, especially for women who these new biotechnologies fail. In the next generation we are likely to have a whole cohort of women suffering post-IVF trauma just as in our generation we have had so many suffering from post-abortion trauma. And yet again we can expect denial all round.

For children, too, IVF is fraught with danger from the beginning: death before birth is, as we have seen, the most likely outcome. Those who are lucky enough to approach the birth point are much more likely to be prematurely born, with very low or low birthweight (and all the attendant risks), or with major handicaps, than are their naturally conceived cousins in the same hospital nursery. The risks of the next generation of reproductive technologies, such as genetic engineering, for those children are incalculable and some of them will be hereditary.

We know precious little, as yet, about the psychological effects of these procedures on the children, but psychologists predict identity problems and other traumas even with simple IVF. It is hard to imagine how the children of the even more complex procedures will be affected. What kind of 'genealogical bewilderment syndrome' will be suffered by the child of multiple parents, or of an aborted foetus' egg, or gestated in a near- dead woman, man, animal or machine, or of an eighty-year-old? The interests of the children seem to get no look-in in these procedures, reflecting yet again how babies are treated not as our moral equals but more as consumer items.

An IVF baby costs a great deal of money. There are now over 10,000 treatment cycles a year here in Britain and the number is growing rapidly despite limited availability on the NHS. Ultimately it would cost billions of pounds to provide assisted reproduction for all who might benefit. This is, after all, a technology which creates its own endless market.

Meanwhile research into the causes, and efforts to prevent, our infertility epidemic are severely underfinanced. Almost nothing is being done to get to the cause of the problem which IVF seeks to address only by relieving a symptom. The World Health Organisation estimates that for the cost of one IVF baby a hundred couples could be prevented from becoming infertile in the first place. And at the same time the healthcare system is terribly over-stretched. IVF, I submit, amounts to a serious distortion of medical research priorities and of resource allocation and thus present us with a major social justice issue.

There are a great many others too who are adversely affected by these technologies in ways I do not have time here to explore: husbands, existing family, donors, health professionals. Societal respect for human life, the dignity of sexuality and procreativity, and the institution of the family are all threatened in various ways.

But my overall conclusion is this: for all its supposed and very real benefits for individual patients and the medical profession, and for all our best efforts to imagine pro-life uses for these technologies, the sad fact is that IVF and related technologies are deadly and they threaten the nature of our society at a very fundamental level. IVF is deadly in several respects: (i) the normal protocol involves intentionally killing or immorally risking the lives of a great many embryonic people in order to achieve a live birth; (ii) it benefits immediately and directly from homicidal research; (iii) it is a by-product of the draws the abortion revolution; (iv) it draws its participants into a corrupting mind-set which views people as consumer products, objects of domination, exploitation and violence; (v) it supports abortifacient research; and (vi) it sometimes covers up for infertility caused by abortion and related violence and irresponsibility. Were this not enough it also harms women, children and society. Pro-lifers have yet another challenge for the century ahead: not just to protect those in the womb and after they leave the womb, but to fight for the rights of people even before they are put into the womb: our tiniest neighbours, the test-tube babies.