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(Pediatrics in Review. 1999;20:E34-E35.)
© 1999 American Academy of Pediatrics
Introduction
This response to "The Ethics of In Vitro Fertilization" will address several issues: social and physical stresses on women, avoiding harm and doing good, questions of autonomy and justice, personhood, and the treatment of embryos and fetuses, especially multifetal pregnancy reduction.
Pressures on Women
Donchin has hard words about pressures on women: "With thec advent of new fertility technologies, social pressure to produce biologically related children is again intensifying," "... infertile women are urged to fulfill their `full reproductive potential' regardless of economic, psychological or bodily cost," and "... feminist analyses frequently show how the market for these techniques is socially constructed." (Donchin, 1996) Nevertheless, Donchin maintains that there is a strong emotional need that is not influenced by social pressures. This need even has been called instinctual, which is reminiscent of the famous "maternal instinct" that supposedly endows women with an inborn knowledge of nurturing behavior, but that actually is learned. New mothers, after all, must be taught how to nurse their infants!
Infertility is not simply a biologic problem to be solved by the appropriate technology. It is a "... socially defined and interpreted category...." (Sherwin, l992) Neither Donchin nor Sherwin deny that women desire biologic children, but they emphasize the social and economic pressures that far too often are downplayed or ignored. Men also are pressured to father biological children, especially now that research has shown that the problem of infertility is not always the woman's.
The actual procedures of in vitro fertilization (IVF) tend to be described in a rather detached manner. One seldom hears details such as: "... some number of the newly fertilized eggs are transferred directly into the woman's womb, with the hope that one will implant itself into the uterus. This procedure requires that a variety of hormones be administered to the woman (often leading to dramatic emotional and physical changes), that her blood and urine be monitored daily at three-hour intervals. In some programs the woman is required to remain immobile for forty-eight hours... (including up to twenty-four hours in the head-down position). This procedure may fail at any point and, in the majority of cases, it does. Most women undergo multiple attempts." (Sherwin, l992)
Much of this passage describes discomfort and inconvenience, and one hopes that the technology will be improved with time, but the administration of drugs with unknown long-term effects and potential for harm to the women receiving them is a continuing problem. Repeated endocrine "storms" may not be benign therapy.
The Harm Principle
The harm principle, which probably is being violated in the use of infertility therapies, is entirely insufficient as a basis for the ethics of health-care professionals. Doing good should be the central principle guiding their behavior. The central question then becomes: What good will come of the procedure? Will unacceptable harms be inflicted in the process of achieving that good? The low success rate of IVF and the actual and potential harms involved suggest that these questions are particularly appropriate.
Respect for autonomy should not be violated in the interest of doing good. This principle includes a very strong requirement for informed consent. Just how well informed are the women who consent to the complex procedures of IVF? Ethics research in this area might be very revealing. Are women truly made aware of the low success rate and the threats to their health? Should they be informed that they are, to some extent, subjects of experimental therapy? If they are well-informed, does consent cure all, or should physicians refrain from offering untested therapies?
Our health-care "system" already accepts so many violations of distributive justice that one more draws very little attention. Infertility treatments are available only to those who can pay for them. Insurance coverage for urgent health problems is increasingly threatened, so it is very unlikely that such very elective and not very successful forms of treatment will be covered in the near future. Do the infertile poor suffer less than the well-off? Are the charges reasonable or exorbitant? The Italian national health service is planning to cover infertility therapy. The outcomes will be interesting indeed!
Personhood
The term person was not used in ancient Greek or Roman philosophy. Persona was the name of the mask worn by an actor. In the third century C.E., person was used in trinitarian theology: three persons in one substance. Perhaps this origin should eliminate any further use because it may violate the separation of church and state. The problem with definitions of person is that they so often are followed by definitions of what is not a person. Once the concept of nonpersons is accepted, the way is open for mischief at the least and real evil at the worst. McCormick calls one of these ventures an effort to establish a category of protectable humanity, from which many humans are excluded, and responds: "Anyone who would attempt an even tentative personhood inventory is trying to catch, bottle, and display what most men have regarded ultimately as a mystery." (McCormick, 1981)
Personhood defined by the needs and values of a community is a perilous idea and rather open-ended. Who knows what these needs and values may turn out to be? The definition of personhood as beginning at birth in this country is a legal one, and this response is concerned with the ethical. They are not identical.
Multiple Pregnancies
Multiple pregnancies is a complication of IVF. The medical response to this has been to reduce the total number of fetuses at about 8 weeks of gestation. Here is the comment of an obstetrician who is a pioneer in perinatology: "Multifetal pregnancy reduction is an aggressive approach to a difficult problem ... The technique is effective, but with high rates of miscarriage, early preterm rupture of membranes... higher rates of preterm birth and growth restriction. Most of these cases result from a medical intervention in the first place (emphasis added). ... preventive methods, such as limiting to two the number of embryos transferred... and better control of the use of ovulation induction drugs, remain more effective and less intrusive." (Papiernik, 1998)
Conclusion
Whatever the "metaphysical" status of the pre-embryo, embryo, or fetus, he or she represents a human life. IVF seemed like a good idea at the time. Now we are discarding embryos, freezing them, "creating" them, fighting over them in lawsuits as "property", manipulating them, cloning them, flushing them out for genetic scrutiny. All of this may be legal, but are we sure that it is ethical?
Suggested Reading
Donchin A. Feminist critiques of new fertility technologies. J Med Philos. 1996;21:476-497
McCormick R. Notes on Moral Theology 1965 through 1980. 1981:444-445 University Press of America Lanham, Md
Papiernik E, Grange G, Zeitlin J. Should multifetal pregnancy reduction be used for prevention of preterm deliveries in triplet or higher order mutiple pregnancies? J Perinat Med. 1998;26:365-370[Medline]
Sherwin S. No Longer Patient. Feminist Ethics and Health Care. 1992 Philadelphia, Penn.: Temple University Press
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