Ethics: In Vitro Fertilization
CONTENTS:
The Issue of Infertility
The In Vitro Fertilization Procedure
A Theology of Infertility
A Theology of Procreation
A Theology of Life
Recommendations and Conclusions
Gary and Jackie came to me following a morning worship service and asked
for an appointment. By the look on
their face, it was obvious that they had a serious concern.
I took them aside for a moment and asked if there was anything I could do
for them, and though they said we could discuss the details later, they informed
me that they were having trouble getting pregnant and were now considering an
attempt at in vitro fertilization.
I was aware that Gary and Jackie were trying to get pregnant for several
years. They had spoken to me about
adoption at one point seeking a referral to a reputable Christian agency.
However, their physician had recently explained in vitro fertilization
and said that they would be strong candidates for the procedure. Given the
doctor’s explanation, the couple suspected that there were some moral
implications and they wanted to seek my opinion before proceeding.
In
just a few days, we would meet and they would need to hear what God would say
about the option based on His word. Helping
them with their decision would require that they understand the steps involved
in the procedure, the risks and probability of success, and the biblical
teaching on life and reproduction.
Medical
experts categorize a couple as infertile if they have been trying to get
pregnant for at least twelve months. Based
on that definition, there are as many as 2.5 million infertile couples in
Couples
seeking to get pregnant need first of all to understand that even under the best
of circumstances there is a 15% to 20% chance of getting pregnant in a
particular month. Medical experts
predict that 85% to 95% of healthy couples should be able to get pregnant after
one year. Therefore, failure to get
pregnant in less than one year should not necessarily cause alarm (Albrecht and
Schiff 1994, 515).
However,
once a couple reaches the one year mark, there are a variety of treatments
available to improve their chances of pregnancy.
These treatments include simple, non-invasive methods such as attempting
to predict ovulation and planning sexual intercourse during the appropriate time
frame. Men should also realize their
role in getting pregnant. About 30%
of all infertility is due to male factors alone. (Albrecht and Schiff 1994,
516). Thus, men will likely be asked
to provide a semen sample for analysis.
If
simpler methods and tests do not help, there are more high-tech methods to which
couples may resort in an attempt to get pregnant.
These methods include the use of infertility drugs such as Clomid or
Perganol to stimulate increased ovulation, artificial insemination (AIH, AID),
surrogacy, egg donation, in vitro fertilization (IVF) and its related procedures
called GIFT and ZIFT, along with a variety of other treatments.
In all, it is estimated that there are about 38 ways to get pregnant
(Mitchell and Buckley, 2).
With
advancements in medical technology and increased availability of infertility
treatment, a remarkable number of births have come as a result of less than
natural means. In the
The
In Vitro Fertilization Procedure
One of the high-tech options included in the ART count noted above is in
vitro fertilization (IVF). IVF was
introduced in 1978, and since that time more than one million babies have been
born worldwide using the procedure. In
order to evaluate the ethical implications of such a procedure, one must first
understand the steps taken to accomplish a successful IVF.
The medical process is described in Carla Harkness’s book The
Infertility Book and Mitchell and Buckley’s pamphlet on “Infertility and
the New Reproductive Technologies” (Harkness 1987, 173-177; Mitchell and
Buckley, 5-6).
The
first step in the procedure is to give the woman a follicle stimulating hormone
(FSH). Though a woman normally
produces one egg (ovum) per month, this medication causes the woman’s ovary to
superovulate, that is, produce several follicles each containing an egg ready
for fertilization. The follicles are
then removed from the woman and prepared for fertilization.
The next step is to fertilize the ova by taking sperm from a donor and
manually, using microscopic instruments, inserting one sperm into the egg to
fertilize it. In order to increase
the probability of success, several eggs are fertilized and allowed to start the
process of cell multiplication. The
fertilized eggs, called zygotes, are then observed and some may be discarded if
they appear to be less healthy or underdeveloped.
The
healthiest zygotes are retained and prepared to be placed in the female’s
uterus. One or more of the zygotes
are placed in the woman’s uterus with the hope that at least one of them will
successfully implant in the uterine wall and fully develop.
Keep in mind that if more than one zygote is placed in the uterus, more
than one may implant and develop resulting in a multiple pregnancy.
If that happens, the couple may be given the option to reduce the number
of embryos by a selective abortion procedure.
This may be done by personal choice or to protect the life of the mother
by reducing the possibility of complications related to multiple pregnancies.
Two
slight variations on the IVF procedure include GIFT and ZIFT.
GIFT (gamete intrafallopian transfer), is performed just like IVF except
that the sperm and unfertilized egg are transferred into a woman’s fallopian
tube instead of being fertilized in a dish and introduced directly into the
uterus. GIFT has some advantages
over IVF in that it is successful up to 40% of the time, while IVF is successful
about 20% of the time (Mitchell and Buckley, 5).
ZIFT (zygote intrafallopian transfer) allows fertilization to take place
in a Petri dish and the fertilized embryo is transferred to the fallopian tube.
Other
important variations on the IVF procedure include sperm and egg donation and
surrogacy. These options are
considered when one or both parties have a substantial infertility problem
wherein they cannot produce an adequate sperm or egg or when the female cannot
adequately carry a child to term.
Regarding
the success rates and risks of IVF, the American Society for Reproductive
Medicine reports that the success rate of IVF is 22.8% live births per egg
retrieval. They also note that this
success rate is similar to the 20% chance that a healthy, reproductively normal
couple has of achieving a pregnancy that results in a live born baby in any
given month (ASRM 1996-98). IVF also
increases the chance of multiple pregnancies.
Usually, two to four embryos are transferred with each IVF cycle.
Of all the pregnancies that result from IVF and end in a live birth,
about 50% are singletons, 24% are twins and 5% are triplets or more (ASRM
1996-98). Put another way, about 30%
of all IVF deliveries were multiple births, more then ten times the rate in the
general population (JAMA 2001, 874).
Infertility
can be a very troubling experience. Couples face a variety of thoughts and
emotions related to their inability to conceive.
Men and women are likely to experience feelings of guilt, inadequacy,
fear, anger and grief similar to reactions to the death of a loved one
(Worthington 1987, 226-228). Couples
and individuals respond differently to the problem, but it is important for
family and friends to be sensitive to the struggling couple especially around
holidays such as Mother’s Day or during the celebration of the birth of
another person’s child.
An important way for couples to cope with infertility is to see how the
scripture speaks to the issue. First,
the Bible tells us the bearing of children is good, and parenthood, when
possible, is to be celebrated. Starting
with the story of creation, God has indicated that procreation is a blessing.
In Genesis 1:28, Adam and Eve are given the command to “be fruitful and
multiply.” The Psalmist reminds us
that children are a blessing from God when he states: “Behold, children are a
heritage from the Lord, the fruit of the womb is His reward.
Like arrows in the hand of a warrior, So are the children of one’s
youth. Happy is the man who has his
quiver full of them” (Psalm 127:3-5a, NKJV).
Children even had a special place in the ministry of Jesus (Matt. 18:1-6;
Mark
However, it is equally clear in scripture that the sovereign Lord is the
one who opens and shuts the womb (Mitchell and Buckley, 8).
In I Samuel 1:5, we are told that “the Lord had closed [Hannah’s]
womb.” For reasons that are not
always clear, God wills many events to take place in our lives that remind us of
our frailty and his sovereignty. While
children are a blessing from the Lord, the ability to bear children is subject
to the mystery of God’s providence. Therefore,
we must submit all our desires, even the desire of bearing children, to the will
of God. James cautioned us that
instead of brazenly following our own wills, we should say, “’If the Lord
wills, we shall live and do this or that’” (James
Even still, God’s plan is always for His glory and, by His grace, in
our best interest. God tells us in
Romans 8:28-29 that all things work together for good for His children in order
that they might become more Christ-like. It
may not be God’s will for a couple to have children; therefore, such couples
should not be treated as second-class citizens.
But trials and disappointments in life can teach believers to pray, as
Hannah did, or can lead couples in other directions of blessing such as
adoption.
Trials
such as infertility can also expose sinful thinking or behavior.
An infertile couple will almost certainly deal with feelings of jealousy
and envy of other couples. Yet the
tenth commandment warns us not to set our desire on things which are not ours. (Douma
1996, 340-341). Coveting in such a
way can lead to sinful behavior. Just
as King David’s desire for Bathsheba led him to pursue immoral means to
satisfy his desires, a couple facing infertility can be faced with immoral
methods to achieve their desire for a child of their own.
There is nothing inherently evil about desiring a child, but this
commandment forbids us to nurse that desire and to develop and implement an
immoral plan to satisfy the desire. Drawing
the line between what can morally be done to pursue a child and what is morally
wrong in that pursuit takes much discernment and prayer on the part of the
troubled couple. This fact must not
be overlooked.
Finally,
the scripture leaves an important option open to couples who face the prospect
of infertility, specifically, medical intervention.
Rae and Core note, “For the most part, technological interventions that
clearly improve the lot of mankind are considered a part of God’s common
grace, or his general blessings on creation.
The use of medicine to alleviate infertility is parallel to the use of
medicine to eliminate other physical effects of the Fall, namely disease” (Rae
and Core 1994, 9-10). Given that
many causes of infertility are a result of the Fall, we should not limit couples
from pursuing medical intervention in order to increase their chances of
pregnancy. Still at issue, however,
is which of the medical procedures are morally permissible and which should be
eliminated from consideration? If a
couple is not careful, a desire for children left unchecked for the sin of
covetousness can lead them to accept immoral medical steps.
In short, medical treatment is appropriate, but it should focus on
treating or correcting the medical condition of the patient and such treatments
should stay within the scope of ethical limits.
The task of procreation is commanded in scripture.
It is a responsibility given to man and woman as the Lord tells them to
“be fruitful and multiply” (Genesis
The
sanctity of marriage and limitations on sexual expression are prominent biblical
themes found in the earliest biblical accounts of Lamech (Gen. 4:19), Abraham
(Gen. 16) and Joseph (Gen. 39) and clearly stated in the eighth commandment (Ex.
20:14). John Murray summarizes the
command and its restrictions well when he states:
We
discover, therefore, that the exercise of the procreative impulse and compliance
with the divine command to be fruitful are not to be given unrestricted and
indiscriminate scope. The
institution of procreation is circumscribed.
It is only within the marital bond that a man is to know a woman, and
only his wife may he know. And since
the marital bond is monogamous, only with one wife may a man enter into conjugal
intercourse (Murray 1957, 46).
Therefore, it is important for
us to identify scriptural restrictions on the procreative process in order to
determine the boundaries which must be set related to the IVF procedure.
The
theme of scripture is that marriage is an exclusive spiritual and physical
relationship between husband and wife. This
is the thrust of the seventh commandment and every related story or teaching in
scripture. For this reason Douma, in
his discussion on the seventh commandment, eliminates artificial insemination
with sperm from a donor (AID) as an appropriate infertility treatment.
Even though we cannot speak of physical adultery, we can speak of
artificial adultery since the child becomes physically that of another man.
As Douma puts it, AID “really involves a ‘someone’ and not merely a
‘something’ of that someone” (Douma 1996, 253).
The
same issue applies to egg donation or sperm donation to accomplish fertilization
in a Petri dish as a part of the IVF procedure.
Though physical adultery does not occur, fertilizing a donated egg or
fertilizing an egg with donated sperm constitutes a breach in the marital bond.
The result is a child that is not physically that of the husband and
wife. Though the process of
fertilization does not involve physical contact between the contributors of the
gametes, the psychological and emotional connection is still a factor and the
end result, a child with a parent outside of the marital bond, is still the
same.
Not
only at issue is the prohibition to commit adultery, but also the injunction
that believers live life within the confines of God’s covenants and commands
and that we trust God for the results. The
story of Abraham and Hagar is an ancient illustration of this principle.
When Abram and Sarai were unable to conceive a child, Sarai told her
husband to take her maid and have a child through her.
Abram and Sarai jumped ahead of God’s plan to provide a child for them.
One consequence of this action which must not be overlooked is the
subsequent resentment Sarai had toward Hagar which lasted a lifetime (Gen.
16:4-6). Thus, issues of procreation
are not just physical; they are very emotional, psychological and spiritual.
The most critical question to be answered in evaluating the morality of
the IVF process itself is, “When does life begin?”
The sixth commandment clearly commands that we are not to kill another
human, but with scientific advances that now allow us to fertilize human eggs in
a Petri dish and view the first multiplication of the tiny embryonic cells, the
theologian is asked to insightfully tell the scientist when the cells have a
soul or at least have the full value of a human being.
The importance of this issue cannot be understated.
One can argue about a mother’s rights or the fetus’ rights.
He can argue about the social, psychological, political or legal
implications of allowing women to terminate a pregnancy.
But the overriding issue is when the cell or group of cells becomes a
life. If agreement were ever reached
on this issue, many other arguments would fall by the wayside.
For the Christian, the answer to this question cannot be found in
philosophical discussion, but in the Bible.
And plentiful discussion about abortion has left us with ample material
about it. This discussion will serve
as a starting point for evaluating the issues related to IVF.
The Christian church has always stood firmly against abortion and
affirmed the value of a fetus. Only
in the past few decades have Christian ethicists turned from condemning abortion
to defending it. Regarding the early
church’s beliefs on abortion, Douma notes that Turtullian, referring to the
fetus, considered something in the process of becoming a human being as already
a human being. And prior to
Turtullian, Christian authors had branded abortionists as “destroyers of
God’s image” (Douma 1996, 218). Likewise,
Calvin, commenting on Exodus 21:22, stated:
...for the foetus,
though enclosed in the womb of the mother, is already a human being, (homo), and it is almost a monstrous crime to rob it of the life
which it has not yet begun to enjoy. If
it seems more horrible to kill a man in his own house than in a field, because a
man’s house is his place of most secure refuge, it ought surely to be deemed
more atrocious to destroy a foetus in
the womb before it has come to light (Calvin, quoted in Douma 1996, 218).
Thus, the early church and the
Reformers as well as the
The Bible passages commonly referred to in defense of this view are found
in Psalm 139 and Job 10:8-12. These
two passages speak of God’s intimate involvement in the development of a fetus
and, most importantly, His knowledge of us in the womb before we are born.
Such intimacy presumes that God values the unborn child like He values
the person he ultimately becomes. If
God values the unborn child, then we too must value it and thus protect it.
However, even with these arguments in mind, IVF takes us to a specificity
of fetal development that Tertullian, Calvin and other theologians may not have
imagined we would go. With every
stage of fetal development from fertilization to birth distinctly defined, we
must now move from general statements about the value of a fetus and speak to
the value of a gamete, zygote, implanted zygote and so forth.
In the IVF procedure there are three specific stages at which one could
attempt to make a determination about the start of life in the eyes of God.
The first stage is with the removal of the ovum from the woman’s ovary
and the acquisition of sperm from the man. These
two cells each contain half of the genetic information for life and
independently cannot produce a living being.
Scripture does not directly state or allude to placing a value on these
cells like that of a human, so the destruction of these cells alone would not
constitute a violation of the sixth commandment which prohibits killing
unlawfully.
The next stage involves the laboratory assisted fertilization of the egg.
This procedure creates a viable cell which, barring any genetic
abnormalities, will begin the process of cell division and lead to a fully
developed human being. This step is
clearly one of the major leaps in the procreative process and is most commonly
referred to the point of conception. It
is at this stage that many theologians point to as the start of life itself.
Mitchell and Buckley, two Southern Baptist ethicists, draw the line at
fertilization by comparing the destruction of a newly fertilized egg with any
other kind of elective abortion. They
state:
Since
individual human life begins at conception, it is immoral to abort fertilized
eggs or embryos. The overwhelming
majority of Southern Baptists and many other evangelical Christians, Catholics,
Jews, and Muslims affirm that elective abortion is wrong.
By extension, any new reproductive technology which results in the
destruction of fertilized eggs should be avoided. (Mitchell and Buckley, 11).
Such is the standard view of
evangelicals on the issue of IVF and when life begins.
A third stage one may consider as the start of life is when the
fertilized egg successfully implants in to the uterine wall of the mother.
Gilbert Meilaender makes the case that we should fix the beginning of
individual human life slightly later than conception:
For one
thing, the fertilized ovum must successfully implant in the uterus before
pregnancy is established, and research seems to indicate that as many as half of
fertilized ova may fail to implant successfully.
If any figure even approaching that is accurate, and if an individual
life begins at fertilization, we would be forced to conclude that half of the
human race dies after a life of four to five days.
Although that is logically possible, it is also rather counterintuitive (Meilaender
1996, 30-31).
The issue Meilaender raises
highlights the complexity in trying to determine the exact point of life’s
beginning when a greater amount of details about the reproductive process is
known. And his point is critical to
those considering the IVF procedure.
As noted above, in the IVF procedure several eggs are retrieved from the
mother for fertilization in the Petri dish.
At this point, the technician can fertilize as many eggs as needed, up to
the number he was able to retrieve. Likewise,
after the ova are fertilized, technicians can observe the zygotes to see which
appear to be more healthy in the early stages of cell reproduction.
Those which appear to be less healthy could be discarded in order to
improve the chances of implantation (pregnancy), unless the couple refuses this
option and insists that all the fertilized eggs be implanted.
The
couple’s beliefs on the beginnings of life will have an impact on the freedom
of the doctors and lab technicians to reduce the number of fertilized eggs to
those they consider to be the most viable. It
will also impact their option to give permission for the physicians to fertilize
more eggs than the couple is willing to have inserted in the uterus in any one
procedure. Extra embryos could be
frozen for possible use in the future by the couple or offered to another couple
like an adoption.
The
key in all of this discussion is the determination of when life begins.
Since the scripture affirms the value of the fetus, we must recognize
that life begins before birth and terminating the development of the fetus would
be an unacceptable act. Though the
Bible does not provide scientific detail about the point a life begins, it does
affirm that life exists in the womb. Furthermore,
without direct biblical evidence to the contrary, it is most reasonable to
assume that life begins at conception since the newly formed embryo has all the
genetic information and the biological capacity to develop into a fully
functioning human. The fact that the
embryo has not implanted in the uterine wall is incidental, thus we reject the
Meilaender’s notion that the embryo is not a life until is has implanted.
Conclusions
and Recommendations
Four issues underlie the decisions which must be made regarding in vitro
fertilization: the validity of medical intervention, a determination of when
life begins, the implications of God’s plan for marriage and family, and costs
for the married couple. With each of
these issues addressed in part in the discussion above, it is time to restate
those conclusions and offer our young couple recommendations regarding the IVF
procedure.
First of all, we affirm that medical treatment for infertility is a valid
option as long as the treatment is designed to correct or assist the body of the
husband or wife with its regular reproductive functions.
The basic purpose of the IVF procedure is to help the wife get pregnant
by manually insuring the egg and sperm unite and placing the embryo in the
uterus where implantation is able to occur.
Such medical intervention is comparable to assisting one’s immune
system by providing a body with antibiotics or assisting one’s heart by
replacing a valve. However,
overstepping the bounds of this principle would include providing a surrogate
mother for the embryo’s development or providing a sperm or egg from a source
outside of the husband and wife. Both
of these options do not involve directly treating the couple’s physical
problems that are a result of the Fall.
Secondly, life begins at conception, or in the case of IVF, at the point
the egg and sperm are united in the laboratory setting.
This conclusion has several implications for the couple considering IVF.
First, the couple should limit the number of eggs fertilized to the
number they would be willing to implant in the uterus.
They should not allow the technicians to fertilize extra eggs in order to
discard embryos they feel are not as healthy.
Likewise, the fertilized eggs should be implanted immediately, that is,
the couple should not plan to freeze or donate extra embryos for adoption or
research. That which God considers
to be a life should not be held in limbo or given an uncertain future and
donating an embryo for research almost always ends in destruction of the embryo.
Furthermore, God did not intend for
us to create a life in order that it may be adopted.
The adoption process exists for a living person who has lost his parents
through a tragedy. Families are
encouraged to consider adoption of a child, but not to create an embryo for
implantation into a different mother.
Thirdly, God’s plan for marriage and family and the scriptural
injunctions against adultery strongly imply that the procreative process should
be an activity exclusively carried out between a husband and wife.
Once again, but on this separate basis, there should be no donation of an
egg or sperm from an outside individual. Such
donation leads to a child that is not an offspring of one of the married couple,
which is the same result as if one partner participated in marital infidelity.
On a related matter, couples should also request that when sperm donation
by the husband is necessary, the wife be permitted to assist in the retrieval
process. Men are generally
instructed to donate their sperm by masturbation.
They may be given pornography for sexual stimulation, but this provides
an occasion for lust and it separates the husband and wife from the reproductive
process. It is more natural and
consistent with scripture to allow the wife to assist in the retrieval process
(Mitchell and Buckley, 12-13).
Finally, a couple should consider the costs of attempting in vitro
fertilization. The financial costs
are definitely a factor since researchers calculate the average cost per
successful IVF delivery at $66,667 to $114,286 (Neumann, Gharib and Weinstein
1994, 239-243). But there are also
other costs. As noted previously,
only around 20% of IVF procedures result in a child carried to term.
The investments of time and emotional energy can strain a marriage
significantly. Other options should
be considered and couples should seek God’s will as they consider this form of
medical treatment.
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