International Catholic University
The growth of modern science in the understanding of human reproduction and the simultaneous growth of modern technology have had significant impact in the field of human reproduction. This combination of knowledge and technology has expanded the power of human beings over the accomplishment of reproduction. Knowledge and technology are human goods insofar as they are directive of and used for human flourishing. The accomplishment of reproduction is a human good if it contributes to true human flourishing in morally acceptable ways. The focus of this lecture will be on assisted sexual reproduction, that is, reproduction accomplished by the union of the egg and the sperm through technological means to assist in their union. Human reproduction by way of asexual means, cloning, is a topic treated separately in these lectures.
From the outset, it is appropriate to acknowledge that the existence of a child is a good, that children are among the goods toward which marriage inclines, and the accomplishment of children as one of the ends of marriage must intend the good of the child as well as the good of the parents. This lecture will (1) present the advances in reproductive technology, (2) present the teaching of the tradition that informs and guides the use of the new technologies as they intend the end of reproduction, (3) present some of the ethical problems that arise in the use of the new technology (the status of the embryo, social justice issues, the right to have children, the basic goods of marriage, the rights of women, the nature of the family . . . children as a product issues) and (4) examine some of the practices and problems that have arisen in the contemporary culture which accepts scientific progress and human desires as the only criteria in determining the goodness of an act.
To set the real world context for technological assistance in reproduction it is necessary to understand the need for such technology. Studies of human infertility report statistics that range from 7% to 18% for the frequency of infertility in couples in the developed world. It is in response to this need that assisted reproductive technologies were developed. At first, the technology was limited to married couples whose desire to have children led them to invest a great deal of time, energy, money, and love to conceive a child. But of course, with the development and success of the technology, it was not long before what had been developed to serve a real human need, became the object of human desire as another service to be purchased. Hence, the demand for the technology expanded. In the contemporary era, the desire by unmarried women for children, for unmarried women to experience pregnancy and childbirth, for women who have been widowed prior to the opportunity to have a child with their husband, and for homosexual couples to have children have fueled the press for more and better technology.
Causes of infertility are varied; some are structural, some are chemical, and some are related to gamete production. If the organs of reproduction are intact in the male and the female, infertility may be caused by the quality of the egg or the sperm. If that is the case, then treatment focuses on the germ cells. If the egg and the sperm are mature and are adequate and available, the infertility may be caused by structural or chemical problems in the reproductive system. Among those problems for women are the occlusion of the fallopian tube -- a condition sometimes caused by scarring subsequent to infection -- or endometriosis unresponsive to medical or surgical therapy or the production of vaginal secretions that are inimical to sperm survival. For the male, the structural impediments include blockages or varicoceles or abnormalities of the ejaculatory ducts or injury to or surgery on the reproductive organs. For both men and women, an unfortunate side effect of chemotherapy and/or radiation is the destruction of gametes and the subsequent loss of fertility. Finally, it is generally acknowledged that the increased incidence of sexually transmitted disease brought on by casual sex is one of the factors imputed to contribute to the increased rate of infertility.
The practices common in the contemporary culture to accomplish the reproductive finality outside of sexual intercourse are generally grouped together under the title "ART" -- for Assisted Reproductive Technologies. Included among these are artificial insemination, in vitro fertilization and embryo transfer, gamete intrafallopian transfer, zygote intrafallopian transfer, intracytoplasmic sperm injection, embryo micromanipulation, embryo hatching, and surrogacy. Because of the speed of the growth of the assisted reproductive technology industry and because of the deliberate cultural ambiguity in regard to abortion, these industries are among the most unregulated in the world. This lack of regulation in a quasi-medical process aimed at the production of children is startling when compared to the difficult and burdensome regulatory procedures in place for the adoption of children.
The following is a brief description of the different types of ART, moving from the simplest to the more complex, now available. If infertility is caused by the inability of the woman to produce mature eggs and her husband is able to produce mature and motile sperm, fertility drugs will be administered to the woman to stimulate the development of multiple follicles and multiple mature eggs. Ovarian hyperstimulation, more often than not, produces multiple mature eggs -- five, seven, or more. If that is the only infertility remedy attempted and if normal intercourse follows, the risk of multiple pregnancies is a real risk and many such pregnancies have been reported. In artificial insemination, the sperm of the potential father or of a donor are injected into the cervix of a woman. Insemination with the father's sperm is designated homologous; insemination with donor sperm is designated heterologous. The sperm travel up through the fallopian tube to fertilize a mature oocyte at the distal end of the fallopian tube. If all goes well, the fertilized ovum, the zygote, begins development as it proceeds down the fallopian tube to a uterus that should be a receptive and appropriate host for the implantation of what is now the embryo. In vitro fertilization is a laboratory process. Sperm from the potential father or the donor is placed in proximity to an oocyte(s) from the mother or a donor in a laboratory dish. The oocytes are produced by hormonal hyperstimulation of the ovaries of the egg donor. The eggs are then harvested by either laparoscopy surgery or ultrasound guided follicular puncture. Usually, because of high rate of failure of the process, more than one oocyte is used and fertilized. If the attempt at fertilization is successful, that is, if syngamy occurs and cell division commences, the embryos are produced. The embryos are transferred in a timely manner to an appropriately prepared uterus, either the mother or the surrogate, for implantation there. The usual procedure, again because of high rate of failure, is to transfer multiple embryos to the uterus and to freeze other embryos for future use, if necessary. Gamete intrafallopian transfer (GIFT) is a process which transfers sperm and eggs in a special catheter, which keeps the sperm and eggs separated, to the distal end of the fallopian tube, where fertilization takes place. In the GIFT procedure, fertilization takes place within the body of the woman who intends to be the mother and, generally, the sperm of the spouse of the woman is placed in the fallopian tube. The greater success of the GIFT procedure is attributed to the fact that it more closely mimics the natural process of conception. Zygote intrafallopian transfer (ZIFT) is the transfer of the zygote, the fertilized ovum, to the fallopian tubes through which it should traverse into the uterus. Intracytoplasmic sperm injection (ICSI) is the injection of a single sperm directly into the cytoplasm of the egg. This procedure is done when the concentration of sperm is low or when the sperm evidence poor motility or when sperm supply is limited such as is the case in men who, on account of illness or medical treatment, have stored sperm for use in generating biologically related children. The availability of the ICSI procedure reduces the need for multiple donor sperm and makes possible the maintenance of the biological tie of the father to the offspring. Embryo micromanipulation is a process in which the sperm and/or the egg are manipulated through microscopic procedures that enhance the quality of the sperm or the egg to increase the probability of fertilization. Assisted hatching is a procedure that modifies the zona pellucida -- the membrane which surrounds the egg -- by opening the membrane or thinning the membrane to facilitate embryo hatching and the subsequent implantation of the embryo into the wall of the uterus.
To all of these manipulations of egg and sperm, the possibility of surrogacy must be added. As methods of reproductive technology have expanded, so too have the methods of surrogacy. Now the idea of surrogate motherhood is not new. Recall Abram and Sarah and Hagar . . . and recall too the problems which followed. Biblical surrogacy, though, required sexual intercourse. The new technologies render sexual intercourse unnecessary for surrogacy. For completeness of treatment, there is a distinction made between two types of surrogacy. In traditional surrogacy, a woman is inseminated by sperm for the purpose of conceiving and bearing a child for someone else. The woman is the donor of the egg and, therefore, she is, by that genetic material, biologically related to the child. Once the child is born, the child is given over to the commissioning couple or the commissioning person to be reared by that couple or person. In gestational surrogacy, the child is not conceived in the body of the woman who will carry the pregnancy forward and give birth. The child may be conceived in any of the many ways described in the assisted reproductive technologies and transferred to the body of a female for gestation. This makes possible a variety of different relationships. The child may be genetically related to either or both the commission parties, or to none or neither of the commissioning parties. This complexity leaves open the possibility that a single child may be related to an egg donor, a sperm donor, a gestational woman, and a rearing person or persons.
All issues regarding the reproductive finality -- whether to have children or to avoid having children -- are to be addressed with the tradition's understanding of marriage. Marriage is understood in the Roman Catholic tradition to have an essential nature, to have several finalities or ends to be accomplished within marriage, and to exercise governance over the reproductive finality from within this understanding of the nature of marriage. Within the tradition, knowledge about the nature of marriage resides in many sources. Among those sources are the (1) Scriptures, (2) the two signs of marriage, (3) Natural Law understood as the work of human reason in its apprehension and affirmation as good the ends of marriage and its command to actualize the goods of marriage, and (4) the teachings of the Magisterium as it applies the wisdom drawn from these sources to the advancements of science and medicine.
The Scriptures address marriage in the very first book -- the Book of Genesis. The divine institution of marriage was "from the beginning" in God's creation of man and woman, in God's image and likeness, for each other (Gn. 1:26); in God's creation of man and woman so that in their union, they become one (Gn. 2:18, 22-23); and in God's command that they "Be fruitful and multiply; fill the earth and subdue it" (Gn 1:27-28). What is being affirmed here is that marriage has as its nature a union of one man and one woman; human beings are to exercise providential creative power; and children are understood as a good of marriage.
The two signs of marriage are the love of Christ for His church and marital intercourse. Thomas Aquinas developed the theology of the two signs in the Summa theologiae in the Supplement, q. 44, a.1. Love of Christ for His bride the Church is the sign which signifies the reality of marriage. Marital intercourse is the sign which both signifies and contains the reality that is marriage. There is then a correspondence between marital intercourse and the nature of marriage. And, on Natural Law principles, there is a claim that the understanding of both is the same. Hence, a more complete understanding of marital intercourse leads to a more complete understanding of marriage; a more complete understanding of the nature of marriage directs the activity of marital intercourse.
The modern treatment of the nature of marriage begins with Casti connubii of Pope Pius XI and moves forward from there to the encyclicals of Pope John Paul II. While it is not possible to present in full the teaching and the development of the teachings on marriage, it is appropriate to present the essential elements of the teaching and the essential development. Casti connubii is the pivotal document for the contemporary treatment of marriage. It summarizes the history of the tradition and it supplies the foundation from which the tradition continues its development. In its summary of the tradition the following themes are present: "the Hebrew emphasis on procreation, the anti-gnostic teaching of Timothy, the Augustinian doctrine of marital goods [fides, proles, sacramentum], the Thomistic view of the nature of the coital act, the nineteenth-century theology of the sin of Onan" (Noonan 1986, 427).
In setting down the nature of marriage, Casti connubii maintains that marriage is a divine institution; marriage is a sacrament; and marriage is an intimate union. As divinely instituted, marriage has a specific nature. Inasmuch as marriage has a nature, men and women are not free to define what marriage is. Men and women are at liberty to enter into marriage with a particular person by a free-will decision, but not to choose the nature of marriage. Marriage as a sacrament is claimed to be "the principle and foundation of domestic society" and "a truly great sacrament of the New Law" (Pius XI 1941, 1). To consider marriage as a sacrament is to recognize it as a graced state in which the grace of the sacrament perfects the natural condition of marriage in order to direct the spouses to the attainment of their proper supernatural end. From its sacramental character flow the indissolubility and firmness of marriage and the sanctification of husband and wife. The intimate union of marriage is a joining of souls and bodies, "the souls of the contracting parties are joined together more directly and more intimately that their bodies" (ibid. 7). What is being maintained here is that marriage involves not just bodily union but the union of two persons brought together by a free, firm, deliberate act of their wills. The operant understanding of marriage in Casti connubii is that it is a procreative institution, an institution in which partners accept their role as cooperators with God in the task of procreation. While Pius XI continues to speak of the human good in terms of the good of the body, the notion of marriage as an intimate personal union appears in inchoate form in Casti connubii.
The explication of the nature of marriage during the long pontificate of Pope Pius XII is presented in his Allocutions. While there is considerable continuity in the tradition from Pius XI to Pius XII, but there is also development of the tradition as new issues came to the fore and as advances in medical knowledge and technology continued. Pius XII, in addressing the notion of the human good, spoke repeatedly and explicitly of the good of the whole person. The nature of the whole person rather than the biology of the body came to be regarded as governing. While there are occasional references to marriage as a special kind of human relationship, the operant understanding of marriage continues to be that of a procreative institution. However, in the presence of advancing technology, Pius XII was pressed to examine the question of the morality of artificial insemination. While artificial insemination intends the good of procreation, the good is accomplished outside a specific act of conjugal intercourse. Artificial insemination was assessed by the Pontiff as an evil; it was found to be violative of the personalist, relational, unitive aspects of marriage. With this treatment of artificial insemination, there begins a transition in the description of the essential nature of marriage. Marriage begins to be considered a procreative union with two distinct ends, procreation and union.
The question of the nature of marriage was revisited in the Second Vatican Council. In Gaudium et spes, a major document of the Council, the claim that marriage has an essential nature persists; however, there is an explicit emphasis on the essence of marriage as an intimate partnership of marital life and love, rather than considering marriage exclusively as a procreative institution. Marriage is described as a covenant between two persons in which there is a mutual giving and accepting of persons. Union and procreation are acknowledged as the ends of marriage; however the ends of marriage are no longer hierarchically ranked as primary and secondary. Conjugal intercourse as an expression of marital love is valued in itself as nurturing the marital union. Conjugal intercourse is not required to have a special motive, such as procreation or remediation of concupiscence, to give it moral character.
Pope Paul VI continued to examine the teaching of the tradition in regard to the nature of marriage and the accomplishment of its ends. He received the report of the Pontifical Commission for the Study of the Problems of Population, Family and Births that had been established by Pope John XXIII. The commission had been charged with the task of gathering information regarding married life and the regulation of conception within marriage. When the commission presented its final report, it included the Majority Report that issued from the theologians. The Majority Report included the assessment that the actualization of the procreative potentiality is to be understood as a requirement of the entire course of the marriage rather than a requirement of every single act of intercourse within marriage. The Report argued that the moral specification of marriage, considered as an act in itself, derives not from particular acts which constitute partial aspects of marriage but from the set of acts throughout the duration of the marriage.
Following the work of the Council and the work of the Pontifical Commission, Pope Paul VI issued the encyclical Humanae vitae. The encyclical reiterates the claim of the two essential aspects of marriage -- procreation and union and it reaffirms the essential act of marriage -- conjugal intercourse. And he sets forth an additional claim, that is, the claim that there is an indissoluble connection between the unitive signification and the procreative signification of the conjugal act. This indissoluble connection is so binding that its deliberate sundering is forbidden. The encyclical states that there is an "inseparable connection willed by God and which man may not break on his own initiative" (Paul VI, 1968, 12).
Donum vitae, The Instruction on Respect for Human Life in Its Origin and on the Dignity of Procreation, was prepared by the Congregation for the Doctrine of the Faith under the direction of its prefect, Joseph Cardinal Ratzinger. It addressed new technologies, such as in vitro fertilization and embryo transfer, surrogacy, and gamete intrafallopian transfer, from within the teachings of the tradition, and, it developed a defense of the inseparability principle -- the inseparability of procreation and union in every act of conjugal intercourse -- which had been articulated but not defended in Humanae vitae. The conclusions of Donum vitae are the following four. First, heterologous artificial insemination is forbidden. Second, surrogate motherhood is forbidden. Both of these involve third party intrusion into the union constituted by the marriage partners. Third, the procedure of homologous artificial fertilization and embryo transfer is forbidden. It is claimed to be an instance of third party intrusion -- here the doctors and scientists -- into the marriage; it is accomplished outside the bodies of the marriage partners; it violates the inseparability principle; it is an instance in which technology dominates rather than serves the human good; and it is violative of the special dignity of the transmission of human life. Fourth, some forms of assistance, such as GIFT, are permissible provided that the procedure is one that facilitates the accomplishment of the inseparable goods of marriage.
In all of his writings on the marriage and the family, Pope John Paul II maintains the focus on family as grounded in marriage as a consortium totius vitae. Family and marriage are inseparable. The gift of self in love has spousal meaning. This meaning requires respect for the biological laws inscribed in the persons of the spouses. Procedures that are inconsistent with respect for life and bodily integrity; procedures that are inconsistent with respect for the family and respect for the origin of the child; procedures that are inconsistent with respect for the integrity of human sexuality are not morally acceptable.
The essential elements in the tradition as developed from Pope Pius XI to John Paul II are (1) marriage is an intimate partnership of love and life; (2) there are two essential aspects of marriage -- procreation and union; (3) the essential act of marriage is conjugal intercourse; and (4) there is an indissoluble connection between the unitive signification and the procreative signification in the conjugal act.
The Religious and Ethical Directives for Catholic Health Care Institutions are framed from within this understanding of the nature of marriage as developed in the documents of the tradition. The directives guide practices for Catholics and for Catholic institutions. Directives 38-42 focus on issues of assisted reproduction. Assistance to married couples in attaining the reproductive finality of marriage is permitted so long as the assistance respects the inseparable bond between the procreative end of marriage and the unitive end of marriage (Directive 38). The nature of marriage, as a union between one man and one woman and a union within which children are to be born, requires that the gametes must be the gametes of the couple who are united in a specific marriage act (Directives 40-42). Heterologous fertilization of any sort is forbidden as a violation of the unity of marriage. Directive 40 forbids heterologous fertilization as "contrary to the covenant of marriage, the unity of the spouses, and the dignity proper to parents and the child." The directives, recognizing the human embryo as a living developing human being, proscribe any reproductive assistance that involves the direct destruction of embryos. The intentional destruction of the embryo is regarded as the direct taking of human life and, hence, a species of homicide. In addition, the directives forbid the use of any reproductive techniques that involve the production of embryos without the intention of implanting the embryos. Surrogacy is forbidden as violative of the unity of marriage -- a third party intrusion by the gestational mother and by technicians -- and as violative of the unique relationship of mother and child. Commercial surrogacy is viewed as violative of the dignity of women and especially of poor women inasmuch as it views women as objects for reproduction and as it presents an occasion for poor women to exchange the use of their bodies for money (Directive 42).
In addition to the violation of religious principles of the tradition there are other potential harms in these ART processes for the intended offspring, for the mother, for the family, and for society. The first harm to be considered is the potential for physical harm to the intended offspring. There are increasing reports of the frequency of less than desirable outcomes with the use of assisted reproductive technologies. The reports also indicate that the more complicated the procedure, the greater the risk for undesirable outcomes. A recent study at a major teaching hospital with a level three perinatal center reported increases in premature births, defined as births at less than thirty-seven weeks of gestation, and an increase in low birth weights, where low birth weight is defined as less than 2500 grams. Assisted reproductive technologies were listed, along with other pregnancy complications such as older mothers or very young mothers, and socially high risk populations, as a significant contributor to the problem of premature birth and the problem of low birth weights. The perinatal center reported a 9.5% rate of prematurity where a 6-8% rate might be expected and a 7.6% rate of low birth weight where a 5-6% rate might be expected. Both prematurity and low birth weights carry the possibility of complications that require medical treatment and developmental interventions which may or may not ameliorate the condition. The complications, depending on the level of prematurity or birth weight, range from death, to severe congenital malformations, to severe impairment, to cerebral palsy, to developmental delay, to complications that are more easily medically remedied for a normal discharge.
Among the problems that arise in in vitro fertilization and embryo transfer, in addition to the possible physical harm for the individual embryo produced, are the possibility of multiple fetuses and ectopic pregnancies. Both of these present serious survival complications for the fetus and serious medical complications for the mother. In addition, a significant issue arises in the processes which involve the union of egg and sperm and multiple embryo production in the laboratory. If the embryo is a living, developing human being, then it is not surplus material to be frozen, to be donated, to be sold, or to be destroyed. It is a human subject with all the same rights and protections as other human subjects. The embryo, then, must be accorded the same respect given to all other human beings. The lectures on abortion developed and supported the position, with a preponderance of evidence, that the embryo is a living developing human being. Inasmuch as that is the case the embryo may not be destroyed or sold or given away. In the early days of IVF-ET, reputable fertility centers limited the availability of assisted reproductive technologies to marriages deemed reasonably stable; they limited the production of embryos to the number that might be safely implanted and carried to term; and, because they recognized the embryo as a living developing human being, they implanted all the embryos produced. There were no surplus or spare embryos.
The use of hormonal hyperstimulation of the ovaries of women and the possibility of the production of multiple fetuses presents another significant problem both for mother and for fetus. If too many fetuses are conceived, the life of the mother may be at risk. There have been reported cases of pregnancies involving five or more fetuses. In general reproductive centers aim for two pregnancies and recommend fetal reduction, if more than two pregnancies occur. The very neutral language of fetal reduction tends to hide the fact that fetal reduction is the killing of a fetus usually by an injection of some chemical. The process in which the fetus is selected and killed, sometimes causes miscarriage with the unintended and undesirable effect of the death of all the fetuses. In multiple pregnancies, the fetus is at risk for direct destruction or for unintentional death if the uterus of the woman is incapable of carrying the fetuses to term or, perhaps, impairment which may be physical or mental if the womb is unable to be a sufficiently suitable environment for all the fetuses.
Finally there is the social justice issue. There is a natural inclination to want children and to desire children of one's own family line. But if natural conception is not possible, is the use of reproductive technologies the only answer. Is it the best answer? The use of reproductive technologies represents a considerable economic investment -- the costs vary as the process is more complicated and as multiple procedures are required.
The cost of oocytes may be as much as $25,000; sperm, because they are more easily retrieved and more numerous, are relatively cheap. So the cost to produce "my child" may exceed $100,000 and the money may be spent without success. Most fertility clinics report a less than 20% success rate where success is defined as delivery of a child.
The use of assisted reproductive technologies is not without risk even within the confines of the tradition. There are risks to both the marriage and the new human being. Children must be conceived from within the body of the marriage. There must be no third party material assistance whether of germ material or place of maturation. The intimacy of marriage, of necessity, becomes open to the presence of technicians and scientists who have the expertise to assist the couple to attain the good of procreation. Couples must be made aware of this intrusion and take appropriate means to protect their intimacy and to protect each other. Technicians and scientists who will assist the couple must be sensitive both to the dignity of the couple and the sacredness of the new lives whose existence they, with their special technical skills, are privileged to serve.
As this lecture is brought to closure, let me raise several questions. The first question is: in a first-world country where so many children are hungry and abused, in a developing world where so many children are dying from malnutrition and from diseases no longer present in the developed world, and in a world where the number of children orphaned by disease, desertion, and violence, including the violence of war, increases daily, might the efforts of couples to have children be directed more broadly toward rescuing one or more of these children? Might this serve to witness the scriptural exhortation to care for "the least of these?" Second, in a world in which there must be choices among the goods to be pursued including the good of the development of technology -- what ends ought technology serve? When a significant percentage of physicians develop specialties tied to substantial remuneration to serve human desires rather than human needs and when significant resources of the medical community are enlisted to serve those specialties, are there pressing human needs that will remain unmet? How does a society direct its resources, including the resource of medicine? How should the line be drawn between needs and desires? The third question has to do with the development of the tradition. Within the tradition, reproduction is limited to the single acts of a married couple. This is so because conjugal intercourse is the marriage act and the tradition understands conjugal intercourse to instantiate the nature of marriage in each and every act. Inasmuch as marriage in its nature has two inseparable ends -- union and procreation, there may be no procreation without union and no union without procreation.
Now if this is a true understanding of the nature of marriage, then assistance in reproduction is very limited, perhaps only to the GIFT process. This understanding of the nature of marriage has a Natural Law foundation, hence a more fully developed understanding of the nature of marriage always remains a possibility. What might development of the tradition look like if new insight into the nature of marital intercourse led to the affirmation that it is always unitive and sometimes procreative?