Can Nature be a Conscientious Objector?

It is a standing Catholic doctrine that the conception of human beings should take place only in the context of acts of intercourse between married, opposite-sex partners.  Maybe some Catholic practitioners can find some wiggle room in the Church’s declarations, but that usually requires some creative interpretation of texts such as Donum Vitae (1987) which declares the “right of every person to be conceived and to be born within marriage and from marriage.” (The emphasis here is in the original.)  If we go with the spirit of these texts, the Church declares that the front line of fertility treatments offered today are sinful. Inasmuch as the Church makes a case that there is a separate, philosophical basis for these declarations, these fertility treatments are also supposed to be immoral as well.

What’s a conscientious physician to do, if he or she finds that they want to observe this interpretation? Some commentators and physicians now declare that the pathway to fertility lies through Natural Procreative Technology (NPT). These commentators and physicians advise that clinicians be look-out for underlying causes of fertility and treat those rather than deploy donor gametes, IVF, embryo transfer, and other treatments in order to give people the child they want. NPT is, therefore, a call to treat underlying disorders insofar as they stand in the way of conception through acts of intercourse between married, opposite-sex partners. 

Advocates of NPT don’t simply offer this approach to infertility as one option among others. They assert the desirability of identifying and reversing the causes of infertility as the only approach that is consistent with the rights of children to be conceived in marriage as well as the rights of men and women to become fathers and mothers only through one another and only through acts that are unitive of body and soul.  

There are no guarantees, of course, that these approaches must succeed. Not all treatment will lead to success in having a child. For those people who pursue this approach, they can either accept their fertility as a kind of spiritual opportunity for religious growth or they will face anew the question of whether to seek out donated gametes, IVF, embryo transfer, or whatever other techniques will help them have a child.

Advocates of NPT invokes ‘personalism’ as one basis for their objection to most assisted reproductive treatments, but there is no reason to accept their interpretation as the one and only interpretation of what it means to be married or to have a child. Advocates of NPT fall back on one interpretation of human relationships and treat that interpretation as somehow an expression of human nature as such. 

Most people who are looking for help in having children do not seek out clinicians for lessons in the metaphysics of human nature. They hope to enrich their lives by having a child, upon whom they can confer benefits. For most people these ethical reasons outweigh the metaphysical interpretations of others. People are free, of course, to interpret their infertility – even if it continues after treatment to restore fertility – as religiously and morally valuable. Physicians are also generally free to decline to offer certain treatments altogether. Treating these freedoms as concordant with nature itself, however, goes too far since we cannot know nature except as an interpretation.  And when it comes to having children and entering into relationships, one interpretation does not fit all.

See:  B.E. Jemlka, D.W. Parker, R. Mirkes, “NaProTECHNOLOGY and Conscientous OB/GYN Medicine,” Virtual Mentor – American Medical Association of Ethics,  2013 (15): 213-219.

Rolling back promises of anonymous donation

Over the years, a lot of donors have offered their sperm for fertility purposes on the condition that their identities remain anonymous.

This practice, for oocytes as well, has not proved popular in all quarters, since information about the genetics of the donors can be useful in the medical care of children born with those gametes. Not only that, but information about the identity of the donors can be useful in the psychological development of the same children.

Some jurisdictions have moved to make certain information about donors available to children born with their gametes.  That changes the terms of donation in the future, but it does little to resolve matters for those conceived with anonymous gametes.

Some advocates want to roll back confidentiality agreements entirely.  For example, Damian Adams and Caroline Lorbach have said this: “Donor conception practices in Australia have left thousands of donor-conceived people, their families and gamete donors bereft of information. The lack of a nationally timeline-consistent approach to information access has driven these people to seek support and information from self-help groups, online communities and even their own DNA.” They argue that “current practices continue to fail donor-conceived people, their families and gamete donors.” They want “all donor offspring” to have “the right to know their genetic family history,” otherwise “they will continue to suffer discrimination, and potentially risk psychological and physical trauma. “ (See ‘Accessing donor conception information in Australia,”  At:  http://sites.thomsonreuters.com.au/

journals/2012/06/15/journal-of-law-and-medicine-update-june-2012/

By contrast to a Law Reform Committee recommendation to roll back the rule of confidentiality that governed gamete donation for many men in Victoria, Guido Pennings argues that undoing the terms of donation – namely, overriding the promise of anonymity – will undermine trust, do damage to donors and their current families, and drive gamete donors away in the future.

He also describes this ‘right to know’ movement as part of a larger ideology, namely a certain normative understanding of what families are and how they should be constituted. Throwing up obstacles to gamete donation, he thinks, serves to discredit gamete donation and opens the door to not only disclosure of donor identity but to donor responsibility for the children as well.  It’s an interesting interpretation of the right-to-know movement that leaves very little room for anonymity.   (See Guido Pennings. How to kill gamete donation: retrospective legislation and donor anonymity. Human Reproduction 2012 (10): 2882-2885.)

Freezing eggs -- no longer experimental.

The Practices Committees for the American Society for Reproductive Medicine and the Society for Assisted Reproductive Technology have reviewed data regarding the role of cryopreserved oocytes in fertility medicine, and they recommend inclusion of this practice where appropriate in clinical medicine. In other words, they declare that the practice is no longer experimental.  Well, they do offer one cautionary note:  freezing oocytes for the purposes of delaying childbearing, for reasons entirely unrelated to health.  But their own analysis opens the door to doing exactly that, under some circumstances.

The Committees report that similar success rates exist whether using vitrified oocytes or fresh oocytes for IVF/ICSI in regard to fertilization and pregnancy rates. They report no increase in chromosomal abnormalities or birth defects compared to conventional IVF/ICSI. 

The Committees recommend that cryopreserved oocytes can therefore be recommended as appropriate when managing gonadotoxin therapies, ovarian excision, premature ovarian failure, unavailability of sperm from intended partner, and as an alternative for those unable or unwilling to cryopreserve embryos.

The Committees decline to recommend the use of cryopreserved oocytes for – as they say – the sole purpose of circumventing reproductive aging in health women. They say that no relevant data exist for these so-called ‘social reasons’ for wanting cryopreserved oocytes. Relevant data are non-existent they say for the safety, efficacy, cost-effectiveness, and emotional risks. They worry that marketing cryopreservation of oocytes as response to reproductive aging may give false hope and encourage postponement of childbearing.  This would be a mistake they say because of the low success rates for pregnancy of women as they age, especially those who freeze their oocytes after age 38.

Strictly speaking, data may be missing for this group of women, but it is unlikely to be materially different from other uses of cryopreserve oocytes. A woman who freezes oocytes for social reasons may not leave these oocytes frozen for periods longer than is done for other reasons, and the woman might not be of advanced maternal age either. For example, a woman who plans to become a surgeon might well freeze her eggs at age 22, fully intending to use them at age 33. This time span might be no different from a woman who freezes oocytes when having her ovaries removed because of a high risk of cancer. 

The Committees are right that data for these uses is lacking, but there is no reason in advance to suspect that the data that will emerge will be materially different from other uses of cryopreserved oocytes. Some uses of oocyte freezing for 'social purposes' will parallel the ways in which these oocytes are used in other circumstances. So, those are really no longer experimental either.

(The full report is at:  http://www.asrm.org/uploadedFiles/ASRM_Content/News_and_Publications/Practice_Guidelines/Committee_Opinions/Ovarian_tissue_and_oocyte%281%29.pdf )

New Book: "Ethics, Sexual Orientation, and Choices about Children"

My new book -- Ethics, Sexual Orientation, and Choices about Children -- is now available from The MIT Press. 

 

In this book, I trace the history of a debate:  Would it be ethical for parents to  select the sexual orientation of their children? This question surfaced in the ethics literature in the late 1970s and has taken many twists and turns since then.  I report the views of the main players in this debate, and I evaluate them for what they mean for parental rights and the well-being of children.

This kind of choice is hypothetical at this point; there is no known way to ensure the sexual orientation of a child one way or the other. But scientific research has opened tantalizing prospects for extending the reach of parental choice over the traits of their children. Some would want to choose the sexual orientation of their children if they could. And that's where the debate begins:  What would it mean for gay and lesbian people if most parents took steps to have only straight children? Should people be able to choose gay and lesbian children, knowing that they might face disadvantages straight children would not? Various commentators have staked out starkly opposed positions.

One of the signal debates in bioethics today concerns the reach of parents into the lives of their children. My analysis considers sexual orientation as an in-depth case study, but it also offers a way to think about the motives for wanting to choose the traits of children in general, a way to evaluate the methods involved, and a way to assess the social effects of making those kinds of choices.
 
For further information, see http://mitpress.mit.edu/catalog/item/default.asp?ttype=2&tid=13046. 

Homosexuality Ceases Procreation?

CNN aired an interview between Piers Morgan and Mahmoud Ahmadinejad, the President of Iran on September 24, 2012.  Mr. Morgan asked the President about freedom for gay people.  Ahmadinejad decided to inject children into his discussion. 

Mr. Morgan asked the President, “Shouldn't freedom and individuality and all those things extend to people who just happen to be gay? They were born gay.  They weren't made gay. Wouldn't it be great for the President of Iran to say, 'You know what? Everyone is entitled to be whatever sexuality they are born with.' That would be a great symbol of freedom.”

Mr. Ahmadinejad replied by asking “Do you really believe someone is born homosexual?” When Mr. Morgan said that he did, absolutely, the Iranian president said “Let me ask you this: do you believe anyone has given birth through homosexuality? Homosexuality ceases procreation.”  He went to ask “Who has said that if you are doing something ugly. they are denying your freedom? Who has said that?”

Not to be put off, Mr. Morgan noted that the president has two sons and a daughter: “What would you do if one of them was gay?”

The president’s reply was this:  “The proper education must be given. The education system must be revamped. The political system must be revamped. And these must also be reformed and revamped along the way. But if you -- if a group -- recognizes an ugly behavior or deed as legitimate, you must not expect other countries or groups to give it the same recognition?”

I mention this discussion here because of the way in which children play a role. In Mr. Ahmadinejad’s mind, the sterility of two men and two women functions as a strong reason to object to the “ugly behavior” of homosexuality.  In 2007, students at Columbia University laughed at the president when he told them that “In Iran, we don't have homosexuals, like in your country.”

While it may be true that there is not in Iran the public pair-bonding of two men or two women that is almost commonplace in the United States, there are men and women who have and express their homosexuality.  Many of them will be in opposite-sex relationships and have children.  Homosexual men and women do have children, even if many of them in opposite-sex relationships. And the American Society for Reproductive Medicine now counsels its membership to offer reproductive treatments to all parties, independent of their sexual orientation.  

Homosexual acts are sterile in themselves, as are many sexual acts between men and women who are infertile and as are sexual acts that, for one reason or another, are situationally infertile. Homosexuality is not, therefore, alone in ‘ceasing procreation.’ For that reason, the infertility of same-sex couples is no reason to throw up obstacles to social freedom.  

For the interview, see:   http://www.cnn.com/2012/09/24/world/meast/iran-ahmadinejad-interview/index.html

The Ethics of Uterus Transplants

Clinicians at Gothenberg University in Sweden reported  this week that they have carried out uterus transplants with two women, actually four since their mothers were the uterus donors. This is a very long way to go in order to have a child.

Researchers have been investigating this kind of transplant with monkeys and baboons for some time now, but there have been efforts at human transplantation too.  In 2011, Turkish clinicians carried out a uterus transplant, and it has been successful enough that the woman experiences menstruation (No author, 2011).  To date, however, she has not had a child.

In February of this year, a study group offered “The Montreal Criteria for the Ethical Feasibility of Uterus Transplantation in Women” (Lamarck et al. 2012). According to this group’s standards, clinicians must ensure that the woman is medically able to sustain the transplant and that she have uterine factor infertility, namely that she lacks a uterus altogether or that she has a demonstrated inability to gestate.  She must also be competent to make a make a free choice to agree to the risks of the transplant, and this choice must not be the result of some psychological disorder. The woman must also appear to be a suitable candidate for motherhood, namely not show any signs of maternal unfitness. 

One of the most interesting proposed criteria for uterus transplantation is this:  the woman must have either (a) a personal or legal reason to avoid surrogacy and adoption as a way of having children or (b) or her goal must be the experience of gestation.  By itself, this standard is broad enough to permit any woman who wants a transplant – and meets the other criteria – to have one.  In other words, any reason important to the woman is reason enough.

In April of this year, the Gothenburg group signaled their readiness to undertake uterus transplantation (Brännström et al.), and their first efforts involved a woman who lost her uterus to cancer and a woman who was born without a uterus, and their mothers as living donors.

The Gothenberg group did not disclose whether the women receiving the organs had a capacity to have children in other ways.  If they did, clinicians might have been able to retrieve ova from them and use IVF in order to help them have children. This option might not always work, of course, since it has its own failure rates and requires a surrogate mother. 

If the women lack their own ova, however, even if gestate their children – if the transplants succeed and pregnancy occurs –they will be doing so with children that are not their own genetically. Most people seem to want to have children that are genetically related to them, unless they can’t. Some people are generous enough to adopt children who have no genetic relationship at all to them, but others would rather have no children than adopt. In the Gothenberg cases, gestation seems to be as important as anything else.

Ironically, these transplants come at a time when some feminists have been trying to liberate women from gestation altogether. For example, Anna Smajdor has argued for strong research commitments to the development of artificial wombs (Smajdor, 2007). She calls for ‘priority’ for this research, without saying priority over what, but she argues that pregnancy is “barbaric” and the sooner women are beyond its reach the better. 

As I say, uterus transplants are long way to go toward having a child and, especially if the goal is primarily to experience gestation. In the Swedish cases, four women assumed a lot of risk: two in donating their uteruses and two in having uteruses transplanted into their bodies.  That’s a lot of pre-operative psychological evaluation, a lot of pre-operative medical evaluation, surgery, and post-operative recovery. I’m all in favor of autonomous choice with regard to choices about having children, but a healthy dose of feminist skepticism toward gestation is in order here. And that’s all the more true when other options for having children exist.

References

Brännström M, Diaz-Garcia C, Hanafy A, Olausson M, Tzakis A. 2012. Uterus transplantation: animal research and human possibilities. Fertility and Sterility (97) [Jun]: 1269-1276. Epub: Apr 28 2012.

Lefkowitz A, Edwards M, Balayla J.  2012. The Montreal Criteria for the Ethical Feasibility of Uterine Transplantation. Transplant International (4):439-47. Epub: Feb 23.

No Author.  2012. First uterus transplants from mother to daughter are reported. New York Times, Sept. 18. At: http://www.nytimes.com/2012/09/19/world/europe/sweden-first-uterus-transplants-from-mother-to-daughter-are-reported.html

No Author. 2011. Nurse hopes to have world’s first baby from a transplant womb donated by her own mother. Daily Mail. Oct. 18. At:  http://www.dailymail.co.uk/health/article-2050401/Married-nurse-hopes-worlds-baby-womb-transplant-donated-MOTHER.html

Smajor, A. 2007. The moral imperative for ectogenesis. Cambridge Quarterly of Healthcare Ethics (16): 336-345.