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Robert G Edwards and the Roman Catholic Church
Reproductive BioMedicine Online (2011) 22, 665– 672
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ARTICLE
Robert G Edwards and the Roman Catholic Church Giuseppe Benagiano *, Sabina Carrara, Valentina Filippi Department of Gynaecology, Obstetrics and Urology, Sapienza, University of Rome, Italy * Corresponding author. E-mail address: [email protected] (G Benagiano). Giuseppe Benagiano, a Professor Emeritus at ‘la Sapienza’, University of Rome, where he became professor in 1980, acted as Director of First Institute of Obstetrics and Gynaecology during 1982–1993 and finally was Dean of Post-graduate School of Gynaecology and Obstetrics. He was nominated Director of Special Programme of Research in Human Reproduction of WHO in 1993 and became Director General of Istituto Superiore di Sanita in 1994. He studied at Karolinska Institute, Stockholm and Population Council, Rockefeller University. His longstanding interest is hormonal contraception; in addition, he pioneered the use of GnRH analogs for gynecological disorders of endocrine origin.
Abstract The Roman Catholic Church reacted negatively to the announcement that the Nobel Prize for Medicine had been awarded
to Robert G Edwards. Thirty-three years ago, Cardinal Albino Luciani, on the eve of his election to become Pope, stated that, whereas progress is certainly a beautiful thing, mankind has not always benefited from progress. Catholic criticism has raised seven points: (i) God wants human life to begin through the ‘conjugal act’ and not artificially; (ii) artificial interventions at the beginning of human life are dangerous and ethically unacceptable; (iii) limits can be imposed even upon an individual’s freedom to achieve a legitimate goal, such as having a child within marriage; (iv) the massive loss of preimplantation embryos characterizing IVF must be considered as a tragic loss of ‘nascent’ human persons; (v) Edwards bears a moral responsibility for all subsequent developments in assisted reproduction technology and for all ‘abuses’ made possible by IVF; (vi) there can be deleterious consequences for offspring of assisted reproduction technology; and (vii) Edwards’ discovery did not eliminate the causes of infertility. This article elaborates from the Roman Catholic perspective on each of these points, some of which are found to be more substantial than others. RBMOnline ª 2011, Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved. KEYWORDS: early embryo wastage, ethics of IVF, Robert G Edwards
Introduction On 14 October 2010, the Nobel Assembly at the Karolinska Institute in Stockholm announced that ‘The 2010 Nobel Prize in Physiology or Medicine is awarded to Dr. Robert G Edwards for the development of human in-vitro fertilization (IVF), a medical advance that represents a paradigm shift in the treatment of many types of infertility’ (Nobelfo ¨rsamlingen, 2010). The Roman Catholic Church reacted to the announcement with a series of declarations by some of its most influ-
ential officials and experts. First came a statement by Monsignor Ignacio Carrasco de Paula, the new President of the Pontifical Academy for Life; the prelate stated to the Italian ANSA News Agency (2010): ‘I believe that the selection of Robert Edwards is totally out of order.’ He went on explaining that he had no intention of negating Edwards’ scientific merits, although there were many reasons that made him perplexed about his choice for the Nobel Prize: ‘first of all, without Edwards there would not be ‘the oocyte market’ with its huge trade of millions of oocytes; second, without Edwards there would not be, all over the world, a
1472-6483/$ - see front matter ª 2011, Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.rbmo.2011.03.004
666 large number of freezers full of embryos, who – in the best case – are waiting to be transferred into a uterus and more probably will end-up abandoned or let die.’ He went on stating that ‘without Edwards we would not have the great state of confusion in the world of assisted reproduction with situations impossible to understand, like children born from foster [in Italian, ‘rented’] mothers’. Carrasco’s final point was: ‘I would say that, at the end of the day, Edwards did not resolve the problem of infertility, which is a serious problem, either from the point of view of pathology or that of epidemiology.’ He concluded that for a true resolution ‘we must wait until research finds another solution, among others more economical and therefore more accessible than in-vitro fertilization (IVF).’ Another Catholic voice expressing perplexity was that of the Catholic priest Roberto Colombo, Professor and Director of the Institute for the Study of Inherited Diseases at the Catholic University of the Sacred Heart in Rome, a member of the Italian National Committee on Bioethics and of the Pontifical Academy for Life. He stated (ANSA News Agency, 2010) that ‘although he recognized the scientific importance’ of Edwards’ discovery, ‘in-vitro fertilization raises serious ethical questions in terms of respect for the beginning of human life and for the dignity of human procreation.’ He went on to say: ‘not everything that is scientifically brilliant, or clinically possible, or legally permitted is licit and in itself devoid of ethical, familial and social questions.’ He then concluded: ‘Although many in these hours are stressing the success of techniques of medically-assisted procreation developed from Edwards’ work, their diffusion in every part of the world, and the large number of babies born through them, without subtracting anything to the scientific and clinical merits of the discovery that received the Nobel Prize, we cannot forget the even greater number of human individual lives, at the stage of embryo development that have been interrupted because of the experimental conditions of their in-vitro culture, of the selection practiced on them, and their non transfer [the Italian word used is ‘implant’] to the uterus.’ Colombo concluded: ‘The primacy of the protection and promotion of human life and of the dignity of the human person cannot be compared with scientific and technological progress, even that with the highest profile.’ Additional negative reactions came from Catholic organizations. The President of the International Federation of Catholic Physicians (FIAMC), Dr. Jose Maria Simon Castellvi, issued a statement denouncing: ‘As Catholics we believe in the absolute dignity of the human person, created in the image and likeness of God,’ and ‘that dignity exists from the earliest moment of the conception of the new human being and remains with them to their natural death.’ The statement went on decrying the use of millions of embryos, thus human beings, created and discarded ‘as experimental animals destined for destruction. This use of human embryos, has led to a culture where they are regarded as commodities rather than the precious individuals which they are’ (Mercopress, 2010). Finally, Catholic members of the European Parliament also criticized the choice of Robert Edwards. Carlo Casini, a prominent pro-life parliamentarian, stated: ‘The assignment to Professor Edwards of the Nobel Prize for science is a source of great pain, because it ignores the hundreds of million of human beings at the
G Benagiano et al. embryonic stage – children – of which in-vitro fertilization has deliberately caused the death all over the world’ (Casini, 2010). Criticism of IVF by prominent Roman Catholic officials is certainly not new and has been made since the first announcement of the birth of Louise Brown. During the days following the announcement in 1978, the then Cardinal Patriarch of Venice, Albino Luciani, granted an interview, some 2 weeks before the Conclave that would elect him Pope John Paul I. This interview was in press when Cardinal Luciani was elected Pope and the Editor decided it was his duty to stop the printing until he could get a formal authorization by the new Pope. Apparently, the Pontiff appreciated the Editor’s discrete approach and promised that he would discuss, among others, this very topic in an audience he was going to grant the journal’s Editorial Committee. As everyone knows, the Pope died prematurely after only 33 days in office. After a while, the Editor decided to publish the interview and the views of Pope John Paul I were made public (Luciani, 1978), although, at the time the publication was ignored by the media. Ironically, in that interview, the future Pope started by saying: ‘In this moment I am not speaking as a Bishop; rather, I am speaking as a journalist consulted by a fellow newsman on a matter as delicate as almost totally new. I put myself in the position of someone who waits what the true Church Magisterium would wish to say, after listening to the experts.’ We said ‘ironically’, because – within days – he would, as Pope, have a special role within the Magisterium he was referring to! Luciani went on by saying: ‘I wish to make four points’ and these will be fully detailed in the next paragraphs. From all these pronouncements certain basic principles came out, although with a different emphasis. The first and most important being that God wants human life to begin through the ‘conjugal act’ and not in an artificial way. Several additional major critiques have been made by Catholic experts against Edwards’ work: the second deals with the unethical and ‘dangerous nature’ of artificial interventions at the beginning of human life; a third stresses that limits can and should be imposed upon an individual’s own conscience and therefore to her/his freedom to achieve even a legitimate goal, such as having a child within marriage; a fourth stresses the massive loss of early, preimplantation embryos that characterizes IVF, a situation that the Church considers as a tragic loss of ‘nascent’ human persons; a fifth attributes to Edwards a moral responsibility for all subsequent developments and therefore for all ‘abuses’ made possible by IVF; a sixth – legitimate in the early days – feared deleterious consequences for offspring; and a seventh makes the point that his discovery did not eliminate the causes of infertility, nor did it solve the plight of most childless women. The lengthy quotations presented above provide ample proof of the magnitude and multiplicity of the criticism levered against Edwards’ work; under the circumstances, an in-depth analysis of all questions raised and of all implications stemming from them will be all but impossible. Nonetheless, this paper will try to analyze from the moral perspective of the Roman Catholic Church, each of these main points, bearing in mind that disagreement is going to continue between those who believe that a couple has an absolute right to have a child, no matter how and independently
Edwards and the Roman Catholic Church of whether the child is biologically theirs, and those who hold that children can morally be brought to life only within the bond of marriage and through natural intercourse. For this reason, the analysis will be limited to addressing each issue exclusively from the perspective of a believer who holds that God intervenes at or after each conception, infusing in every human being an immortal soul. Although it is not known when this happens, a theist outlook requires that human life be considered sacred and therefore be protected from its inception (Benagiano et al., 2011).
In God’s plan, human life can legitimately be initiated only through the natural conjugal act between spouses This argument goes to the heart of Edwards’ work, based on the process of initiating human life outside the female reproductive tract. Back in 1978, the future Pope John Paul I stated: ‘Coming now to the act itself and without reference to the parties’ good faith, the moral problem at stake here is whether extracorporeal fertilization in vitro, or in a vial, is licit. Pius XII, speaking about artificial fertilization within matrimony, made the following distinction: Is the technical intervention of the physician such as to facilitate the matrimonial act between the spouses? Or, does it help to obtain a child, continuing – somehow – an already-accomplished matrimonial act? In this case, there is no moral issue at stake and the intervention can be applied. What if the ‘artifice’ instead of helping or continuing the conjugal act, excludes and substitutes it? Then that intervention is not licit because God linked transmission of human life to conjugal sexuality. This is, more or less, Pius XII teaching; and I do not find valid arguments to dissociate myself from this norm, declaring permissible to separate the transmission of life from the conjugal act’ (Luciani, 1978). This concept was formalized many years later in an Instruction by the Congregation for the Doctrine of the Faith (known in the past as the Holy Office) issued in 1987–1988: ‘These techniques can enable man to ‘take in hand his own destiny’, but they also expose him ‘to the temptation to go beyond the limits of a reasonable dominion over nature’’ (Pope John Paul II, 1980). They might constitute progress in the service of man, but they also involve serious risks. Many people are therefore expressing an urgent appeal that in interventions on procreation the values and rights of the human person be safeguarded. The Instruction then clearly states: ‘From the moment of conception, the life of every human being is to be respected in an absolute way because man is the only creature on earth that God has ‘wished for himself’ and the spiritual soul of each man is ‘immediately created’ by God; his whole being bears the image of the Creator. Human life is sacred because from its beginning it involves ‘the creative action of God’ and it remains forever in a special relationship with its Creator, who is its sole end. God alone is the Lord of life from its beginning until its end: no one can, in any circumstance, claim for himself the right to destroy directly an innocent human being. Human procreation requires on the part of the spouses responsible collaboration with the fruitful love of God; the gift of human life must be actualized in marriage through the
667 specific and exclusive acts of husband and wife, in accordance with the laws inscribed in their persons and in their union’ (Congregation for the Doctrine of the Faith, 1988). Several Christian Orthodox Churches share the Catholic view. As an example, a document issued in 2006 by the Bioethics Committee of the Holy Synod of the Church of Greece states: ‘The way life begins is sacred: physiologically speaking, the exact moment of the beginning of life, within the context of physiology is unknown to man . . .’ At the same time, the Committee noted that: ‘Modern technology introduces us to the logic of sexual intercourse without reproduction and of reproduction without sexual intercourse. The dynamism of technology takes the beginning of life out of the warmth and darkness of the maternal body, out to the coolness and transparency of the test tube. . . . It abolishes the uniqueness of the spouse’s presence by substituting them with medical staff. . . . The child . . . is not directly conceived by his/her parents’ (Nikolaos, 2008). Christian believers within the Catholic and Orthodox traditions therefore enter this debate pointing out that from their perspective, the very moment God infused an immortal soul to Homo sapiens, or one of its predecessors, two dramatic facts occurred and forever changed our universe. On the one hand, the Creator who, according to physical, biological and evolutionary evidence, after the ‘big bang’ let His ‘Intelligent project’ move on through natural evolution (e.g. Collins, 2006), decided to intervene infusing an immortal soul in this new creature and guiding its progress. On the other hand, from the beginning of their appearance on Earth, these creatures started modifying natural evolution, beginning with agriculture, domestication of animals and continuing to our days with medical progress (mostly aimed at modifying the natural course of diseases), transgenic plants and animals and DNA research (also aimed at combating the natural course of negative inherited characteristics). Following this line of thoughts, there should be no reason why the Creator would place one and only one limit to human ingenuity. Obviously, whereas Catholic scientists can legitimately pose the question, they must then abide by the ruling of the Magisterium. Interestingly, this negative position is not shared by Islamic and Jewish theologians. In the case of Islam, initially reactions were negative. Although assisted reproduction is not mentioned in the primary sources of Shari’aa (the instructions that regulate everyday activity in the life of observant Muslims), initially patients and doctors felt that seeking assisted reproduction was a challenge to God’s will by trying to render barren women fertile. In addition, similar to the present position of the Catholic and Orthodox Churches, the idea of artificial handling of human gametes and embryos was rejected. It was only after prestigious scientific and religious bodies and organizations issued guidelines and these were adopted by medical councils and accepted by concerned authorities in different Muslim countries, that IVF became widely seen as an ethical solution to infertility. In Sunni Islam, IVF – excluding gamete donation and surrogacy – is accepted for married couples only. In the same circumstances, Shi’aa Islam permits surrogacy (Serour, 2008). Within the Jewish religion, the development of IVF made it necessary to consider the morality of conceiving a human being outside the womb and the fact that this was even
668 feasible has been considered as proof that embryos have not taken a different character by being created outside a woman’s body and that therefore the technique was permitted (Schenker, 2008). According to Rabbinical teaching, what is important is not where conception occurs, but whether conception is the consequence of the encounter between the gametes of the spouses, based on the commandment of procreation stated in the Bible (Genesis 1:18). This is why, the Jewish majority’s religious point of view, as formulated by the chief Rabbi of Israel supports IVF/embryo transfer (Schenker, 2007). It is important to stress that the issue of legitimacy of interventions at the beginning of human life, is precisely where the proponents of IVF believe that – to use the words of Jacques Cohen, the Chief Editor of Reproductive BioMedicine Online – ‘Edwards is our Galileo’, the one who has opened the way to a Copernican revolution in our approach to reproduction. This position has been echoed by secular philosophers (Benagiano et al., 2011).
The sacred nature of human life and the moral imperative to protect it from its inception The position of the Roman Catholic and Greek Orthodox Churches is unambiguous also on this point. As already mentioned, the 1987–1988 Instruction by the Congregation for the Doctrine of the Faith mandates that ‘nascent’ human life be given absolute protection (Congregation for the Doctrine of the Faith, 1988). This teaching has been repeated and reinforced 20 years later by the Congregation, specifically addressing the issue of early embryonic loss (Congregation for the Doctrine of the Faith, 2008): ‘It should be recognized, however, that given the proportion between the total number of embryos produced and those eventually born, the number of embryos sacrificed is extremely high. These losses are accepted by the practitioners of IVF as the price to be paid for positive results. In reality, it is deeply disturbing that research in this area aims principally at obtaining better results in terms of the percentage of babies born to women who begin the process, but does not manifest a concrete interest in the right to life of each individual embryo. It is often objected that the loss of embryos is, in the majority of cases, unintentional or that it happens truly against the will of the parents and physicians. They say that it is a question of risks which are not all that different from those in natural procreation; to seek to generate new life without running any risks would in practice mean doing nothing to transmit it. It is true that not all the losses of embryos in the process of IVF have the same relationship to the will of those involved in the procedure. But it is also true that in many cases the abandonment, destruction and loss of embryos are foreseen and willed.’ Under the circumstances, the Congregation could only repeat that IVF practices cannot be accepted. Yet, in spite of this repeated formal pronouncement that leaves no space for compromise, the Catholic Church left the door open to one form of assisted reproduction, the all-but-abandoned gamete intra-Fallopian transfer (GIFT) (e.g. Braeckmans et al., 1987) and one might argue that at least one development stemming from Edwards’ work could be judged without a negative eye.
G Benagiano et al. The Catholic position is echoed in the already-quoted declaration by the Bioethics Committee of the Synod of the Church of Greece: ‘The rights of an embryo emerge from the fact that the embryo is a person under development; it is an entity which depends on and results from the will of third persons and is unable to take care of and defends itself’ (Nikolaos, 2008). To strengthen the moral imperative to defend ‘nascent’ human life, during the second half of the 20th century the Catholic Church has placed the age-old debate over the moment of ensoulment (delayed animation versus immediate animation) – so to speak – on the back burner, by shifting emphasis from theology to pastoral care (Benagiano and Mori, 2009). Theology cannot resolve the issue of when ensoulment takes place and therefore when a ‘human life-form’ becomes a ‘human person’ through God’s direct intervention. Therefore, the supreme value of the defence of life from its inception can be better served by stating positively that, after fertilization the early human embryo must be protected ‘as a person’ or, according to Ford (2002, 2008), as a ‘potential human person.’ Here again, the Catholic and Orthodox position is not shared by Islamic and Jewish theologians. In the Muslim World, prevention and treatment of infertility are of particular significance because the social status of women, their dignity and self-esteem are closely related to their procreation potential, both for the family and society as a whole (Serour, 2008). At the same time, Islamic teaching, on the issue of the status of early human embryonic life, stems directly from the Holy Quran itself where it is explained that the development of intrauterine life advances step by step from a clot to a lump of flesh then boned flesh and finally a fully grown infant (Sura El Hag 22:5; Sura El Mo ´menon 23:14). Therefore, according to Islamic theology, ensoulment of the fetus occurs after 120 days following fertilization, although some authorities consider it to occur as early as 42 days post-fertilization (Hadith Sharif). Recently, even this new earlier threshold has been brought back to 14 days after conception, because recent discoveries in human embryology have established that individuality of the new being is achieved at that stage (Serour, 2002). Jewish interpretation of when human life begins is extracted predominantly from Halachic (Jewish Religious Law) sources, because the Bible does not make any direct references to when exactly a new life begins. While the Talmud gives the full status of humanness to a child at birth, rabbinical writings have slightly extended the acquisition of humanness for full-term infants to the 13th day of extrauterine life. The Babylonian Talmud (Yevamot 69b) states that: ‘the embryo is considered to be mere water until the fortieth day.’ Afterwards, it is considered ‘subhuman’ until birth (Schenker, 2008).
The massive wastage of embryos runs contrary to the stated absolute value of human life The denunciation of the ‘massive loss’ of human embryos has been made by Catholic experts more and more forcefully in recent years. If a human embryo has to be considered ‘as a person’ from the moment of conception, it inevitably follows that IVF raises additional ethical
Edwards and the Roman Catholic Church problems when supernumerary embryos are created and then not transferred (whether cryopreserved or not). This is the reason why the Catholic Church threw its full support behind the Italian IVF Law, that makes it mandatory to transfer every embryo produced during an IVF cycle. Whereas the Church does not approve of IVF in any form (with the already-mentioned possible exception of the GIFT procedure), it considers that in a multicultural society, the procedure should not be outright banned; rather, it should be carried out without any loss of early embryos (Benagiano and Gianaroli, 2004). This is because: ‘There is no justification for the reductionism that sees human embryos as no more than genetic products, devoid of moral significance and value. From a theistic perspective, the fruit of human generation in the early embryo has moral significance and a claim to unconditioned moral respect.’ In this view, the deliberate destruction of a human embryo is a serious moral offence against the basic good of human life (Ford, 2002). When it was pointed out that massive early embryo wastage is a natural and physiological phenomenon that cannot be avoided (Benagiano et al., 2010), theists have replied that there is no moral problem with people dying at any stage of life – provided nobody has caused death deliberately, or by lack of due care in the family context, or in a professional medical situation. On the one hand, modern science and medicine enable more lives to be saved before and after birth; on the other, believers in God (and more specifically Christian believers in God’s divine revelation in the historical Jesus Christ) do not accept that death is the end of the entire person. For them, the human soul, unlike that of animals, is spiritual, i.e. immaterial and is not liable to corruption when human individuals die. Catholic teaching holds that the souls of deceased persons do not cease to exist: being immaterial, they cannot corrupt as bodies do. In this perspective, it does not matter how early a human being ceases to exist after conception (Benagiano et al., 2011). Clearly, those who believe that matter and material energy alone exist in this world simply cannot accept the idea that the spiritual soul of a deceased human individual could survive and eventually be united again with a renewed body to form the same living human person as one entity. And even if they might accept it, they would argue that in the event of early embryos or, a fortiori, in the event of aneuploid or polyploid embryos, blighted ova and an embryonic vesicular moles, there would be no person in the first place with which to be reunited (Benagiano et al., 2011). Therefore, most non-believers in God, in spiritual souls or in any immaterial beings would find the above discourse difficult or problematic to say the least. Some might find it out of touch with reality or even bordering on the ridiculous (Mori, 1996, 1998a,b).
The legitimate goal of having a child within marriage is not absolute and ethical limitations should be imposed The future Pope John Paul I in his interview (Luciani, 1978) said: ‘The press, in many countries is sending congratulations to the family and best wishes to the child. Following God who wants and loves human life, I am also sending my most cordial wishes to the baby girl. With regard to her
669 parents, I have no right to condemn them: subjectively, if they acted with right intentions and in good faith, they may even have a great merit in front of God for their decision and for what they asked physicians to execute. We agree that individual conscience must always be followed, both when it commands and when it forbids; at the same time an individual must make an effort to have a well formed conscience. Indeed, conscience does not have the role of creating the law. It has two separate functions: to inform itself about what God’s law says; and to judge whether there is synchrony between this law and a given action by us. In other words conscience must command man, not obey to man.’ He went on saying: ‘I read in the press – ‘‘it is ridiculous to pose moral problems to those availing themselves of magnificent scientific discoveries. And, on top of it, there are the rights of a free individual conscience.’’ Very well, but ethics does not entertain scientific discoveries, it deals with human actions through which persons can utilize for good or bad scientific discoveries.’ This position is still considered valid by the Catholic Church, which refuses to accept that there is an ‘unlimited right’ to have a child.
Edwards bears moral responsibility for all subsequent developments in IVF An indirect response to this argument comes from the Catholic geneticist Bruno Dalla Piccola (2010), President of the most influential Italian pro-life organization, ‘Scienza e Vita’ (Science and Life), who acknowledged that ‘Edwards has had a major influence in the history of medicine’, adding: ‘having made this premise, today, years later we can say that in the practical applications, we are far away from the original spirit of his research. At the beginning the issue was that of overcoming mechanical problems preventing the encounter between the oocyte and the spermatozoa’. Dalla Piccola believes that ‘over the years these techniques have become an abuse and a form of reproductive ‘fury’ [accanimento] thanks to a dramatic economic pressure’, but he said nothing about holding Edwards responsible for every later ‘abuse’ committed. In all honesty, we believe that the argument of his personal responsibility for every subsequent development (irrespective of whether they are considered positive or negative) cannot be put forward. First of all, we must bear in mind that Louse Brown was conceived with one oocyte obtained from a natural cycle and therefore, in this first famous case, there was no embryo wastage whatsoever (Steptoe and Edwards, 1978). In addition, to consider Robert Edwards morally responsible for all subsequent ‘abuses’ perpetrated by those who applied and expanded his technique is like considering Enrico Fermi responsible for the massacres of Hiroshima and Nagasaki.
There are inherent dangers in IVF and infants born from the technique may be exposed to unknown risks The issue of possible risks for offspring of IVF was the subject of strong debate from the early days of Edwards’ research. In the memoir written with Patrick Steptoe (Edwards and Steptoe, 1980), he mentions an episode that
670 is highly descriptive of a view held by many in the 1970s, namely that his experiments would lead to the production of monstrous creatures. At a panel discussion named ‘Fabricated babies: the ethics of the new technology in beginning life’, during a conference in the USA in 1971, famous scientists rose to speak against the work conducted by Edwards and Steptoe. Paul Ramsey, a theologian from Princeton University, denounced their work in very strong terms. As Edwards recounted in the book: ‘He doubted that our patients had their fully understanding consent. We ignored the sanctity of life. We carried out immoral experiments on the unborn. Our work was, he thundered ‘unethical medical experimentation on possible future beings and therefore it is subject to absolute moral prohibition’. Even more astounding was the reaction of James Watson, the scientist who received the Nobel Prize for the discovery of the DNA double helix. Addressing Edwards he stated: ‘You can go ahead if you accept the necessity of infanticide. There are going to be a lot of mistakes. What are you going to do with the mistakes? We have to think about some things we refuse to think about.’ Years later, the future Pope John Paul I used milder words, although, clearly, this was after the birth of the first IVF baby (Luciani, 1978): ‘I share only in part the enthusiasm of those praising the progress of science and technology after the birth of the English baby girl. Progress is certainly a beautiful thing, but mankind has not benefited from every progress advancement. ABC (Atomic, Bacteriological and Chemical) armaments have been ‘progress’, but, at the same time, a disaster for humanity. Whereas the possibility to have a baby ‘‘in vitro’’ does not cause disasters, it does carry major risks. For instance, natural fecundity carries sometimes the risk of malformations; how do we know that artificial fecundity will not carry greater risk of abnormalities? If so, confronted with these problems, wouldn’t the scientist look as the ‘‘sorcerer’s apprentice’’ unleashing formidable forces, without being able to rein them in? Another example: given today’s crave for money and moral unscrupulousness, should not we be afraid that we will see the birth of a new industry, the ‘‘children’s factory’’, perhaps for those who do not or cannot contract a valid marriage? If this happened, wouldn’t the family and society as a whole be in regress, rather than in progress?’ Fear of adverse effects on offspring was only natural during the years preceding Louise Brown’s birth or immediately afterwards; today, however, data have been accumulated indicating that IVF, in its many forms, does not carry unacceptable risks of increased anomalies in children born from the procedures. It is beyond the scope of this paper to discuss the subject and we will limit ourselves to briefly reporting that, in a major survey, Van Steirteghem et al. (2002) pointed out a number of factors that may hamper any comparison of outcome of children born after assisted reproductive technology and those naturally conceived. First of all, the differences in the characteristics of infertile patients such as age and genetic risks. In addition, the type of neonatal surveillance protocol, the number of individuals lost to follow-up, the size of the cohort study and the lack of standardization in defining, for example, major anomalies are all factors complicating true comparisons. Also Ludwig and Diedrich (2002) believe that molecular biological studies support the idea that these risks are not related to the
G Benagiano et al. technique used, but to parental background factors; they point out that data from surrogate motherhood also demonstrate that there the risk is lower as compared with pregnancies from IVF mothers, who carry their own child to birth. At any rate, a wealth of information is today available on children born after assisted reproduction technology. Recent studies indicate that assisted reproduction does not enhance the variability of DNA methylation imprints (Tierling et al., 2010); in addition, the health and neurodevelopment of infants from IVF are similar to those of the general population (Porta-Ribera et al., 2009) and these children do not suffer poorer cognitive development at 3 years (Carson et al., 2010). A different picture came out in the review of the literature conducted by Van Steirteghem et al. (2002) of the limited available data on fetal karyotypes after the technique known as intra-cytoplasmic sperm injection (ICSI). This revealed that in children born after ICSI there is: (i) a slight but significant increase in de-novo sex chromosomal aneuploidy (0.6% instead of 0.2%) and structural autosomal abnormalities (0.4% instead of 0.07%); and (ii) an increased number of inherited (mostly from the infertile father) structural aberrations. Furthermore, in 8319 live-born ICSI children, the mean percentage not originating from singleton pregnancies was 40%, with a range of 32.6–60.8%. Most multiples are twins, but there are also 4.4% triplets (in one survey 13.2%). They point out that this substantial increase in multiple pregnancies must be considered the most important complication of assisted reproduction technology.
IVF does not eliminate causes of infertility, nor does it solve the plight of most childless women Many have argued that infertility is ‘not a disease’ (although it is often the consequence of a disease or a dysfunction). As such, in many infertile women there is no disease to treat; rather there is a need to make conception possible. In this sense, the procedure first applied by Edwards and Steptoe did resolve the problem allowing a woman to conceive and carry her baby to term. It is interesting that in the already-mentioned book (Edwards and Steptoe, 1980) Edwards mentions the opposition to his work by Leon Kass of the US Academy of Sciences, an opposition based on the argument that his work was not therapeutic – women would still be infertile even if the technique successfully produced live children after transferring embryos in them. Edwards commented: ‘That argument surely was scarcely credible. So much medical treatment is directed towards replacing a deficiency rather than producing a cure. Consider for instance the life-saving therapy of insulin for diabetes. Or, for that matter, the value of false teeth and spectacles!.’ More complex is the issue of availability of infertility treatment, an issue that must be considered within the context of inequalities in access to health care. Even the European Union Commission (EC) has acknowledged that gender-based inequalities are present in health care and in long-term care, as well as in health outcomes, within the borders of the European Union (European Commission,
Edwards and the Roman Catholic Church 2010). As pointed out by the EC, what needs to be borne in mind, being very relevant when discussing access to assisted reproduction technology, is the fact that women and men are confronted with gender-specific health risks and diseases which need to be adequately addressed in medical research and health services. Therefore, those stating that IVF cannot, because of its cost and complexity, be practically applied to the majority of couples in the developing world have a point, since availability of assisted reproduction technology is still limited to a minority of women in a minority of countries. Having said this, it is equally true that efforts are being made by many to increase availability and decrease costs; these efforts are important because in a number of countries childlessness is a real curse and infertile women can be divorced simply on the ground that they cannot provide an heir to their families. Tragically, this curse is much more serious in the developing world, where access to assisted reproduction technology is problematic, to say the least. In addition to the personal grief and the moral suffering it causes, the inability to have children, especially in poor communities in the developing world, can produce broader problems, particularly for women; it creates a social stigma, economic hardship, social isolation and even violence. In some societies, motherhood is the only way for women to improve their status within the family and the community. On a practical level, many families in developing countries depend on children for economic survival. For these reasons, the academic discussion whether ‘infertility is a disease’ becomes irrelevant for two reasons: first, infertility is always the consequence of an abnormal, often pathological situation (although, sometimes ‘unexplained’); second, for sure it is a social and public health issue as well as an individual problem. Finally, over the last decades, people from Western countries have cultivated the belief that overpopulation, not infertility, is the major problem of developing countries, creating a practical, but important barrier to even consider infertility treatment in resource-poor countries. What this approach fails to take into consideration is the fact that we are dealing with the personal suffering of individuals, not with global solutions, and we cannot avoid helping these individuals. Clearly, infertility treatment in resource-poor countries can only be considered when two conditions are fulfilled: (i) a minimal level of political stability and a minimal basic structure of healthcare provisions; and (ii) we should be not only discussing high technological interventions like IVF, but including other interventions of a lower technical nature (Pennings, 2008). In summary, the Catholic Church is correct in supporting the right of women to have access to infertility treatment, provided this treatment meets clear ethical standards.
Conclusions We hope to have shown how the critical position of the Catholic and Orthodox Churches towards Robert Edwards’ scientific achievements is diversified and nuanced. The fundamental point at stake for the Churches is respect for human life from its inception and the requirement that a new human life must begin only through natural means.
671 We sincerely hope that those in disagreement with the Churches’ position will respond with valid arguments, so that a constructive dialogue can be established on an issue of fundamental importance for the future of the human species.
References ANSA News Agency, 2010. Nobel al padre della fecondazione in vitro, l’ira del Vaticano [Nobel to the father of in vitro fertilization: the ire of the Vatican]. 05 October, 2010. Available from:. Benagiano, G., Gianaroli, L., 2004. The Italian IVF Law. Reprod. Biomed. Online 9, 117–125. Benagiano, G., Mori, M., Ford, N.M., Grudzinskas, G., 2011. Early Pregnancy Wastage: Ethical Considerations. Reprod. BioMed. Online 22, 692–700. Benagiano, G., Farris, M., Grudzinskas, G., 2010. The fate of fertilized human oocytes. Reprod. BioMed. Online 20, 10–12. doi:10.1016/ j.rbmo.2010.08.011 [Epub ahead of print]. Benagiano, G., Mori, M., 2009. The origin of human sexuality: recreation or procreation. Reprod. BioMed. Online 18 (Suppl. 1), 50–59. Braeckmans, P., Devroey, P., Camus, M., et al., 1987. Gamete intra-Fallopian transfer: evaluation of 100 consecutive attempts. Hum. Reprod. 2, 201–205. Carson, C., Kurinczuk, J.J., Sacker, A., et al., 2010. Cognitive development following ART: effect of choice of comparison group, confounding and mediating factors. Hum. Reprod. 25, 244–252. Casini, C., 2010. Nobel Medicina Ci offende come membri della famiglia Umana [Nobel in Medicine: it offends us as members of the human family]. Available from: . Collins, F.S., 2006. The Language of God. Free Press, Division of Simon & Schuster, New York. Congregation for the Doctrine of the faith, 1988. Instruction on respect for human life in its origin and on the dignity of procreation: replies to certain questions of the day. Acta Apostolicae Sedis. 80, 1–25. Congregation for the Doctrine of the faith, 2008. Instruction Dignitatis Personae, on certain bioethical questions. Available from: . ` accanimento riproduttivo Lo spirito iniziale Dalla Piccola B., 2010. E ` come un intervento: bisogna valutare il rischio e ` stato tradito. E [It is reproductive fury. The initial spirit has been betrayed. It is like and intervention: the risk must be evacuate] Corriere Della Sera, 05 October 2010. Available from: . Edwards, R.G., Steptoe, P., 1980. A Matter of Life. The Story of a Medical Breakthrough. Hutchison, London. European Commission. Communication 491, 2010 (final), from the European Commission to the European parliament, the Council, the European Economic and Social Committee and the Committee of the Regions. Strategy for equality between women and men. 2010-2015. SEC(2010) 1079 SEC(2010) 1080. Ford, N.M., 2002. The Prenatal Person: Ethics From Conception to Birth. Blackwell Publicing, Oxford. Ford, N.M., 2008. A Catholic ethical approach to human reproductive technology. Reprod. Biomed. Online 17 (Suppl. 3), 39–48. Luciani, A., 1978. Non e ` lecita la fecondazione extrauterina [extracorporeal fecundation is not licit]. Prospettive 7, 154–156.
672 Ludwig, M., Diedrich, K., 2002. Follow-up of children born after assisted reproductive technologies. Reprod. Biomed. Online 5, 317–322. Mercopress, 2010. Catholic Church insists in questioning Nobel Prize to in vitro fertilization. 05 October 2010. Available from:. Mori, M., 1996. Is the human embryo a person? No, In: Evans, D., Nijhoff, M. (Eds.), Conceiving the Embryo. Ethics, Law and Practice in Human Embryology. The Hague, pp. 151–163. Mori, M., 1998a. On pre-embryo: the ground of a new ‘‘Copernican revolution’’ on the current view about human reproduction. In: Harris, J., Holm, S. (Eds.), The Future of Human Reproduction. Oxford University Press, Oxford, pp. 38–55. Mori, M., 1998b. Entry: Life, Concept of. In: Chadwick, R. (Ed.), Encyclopedia of Applied Ethics, vol. 3, Academic Press, S. Diego (CA), pp. 83–92. [reprinted also in Chadwick, Ruth (Ed.), The Concise Encyclopedia of the Ethics of New Technologies, Academic Press, San Diego, 2001, pp. 277–285]. A new version is in press and coming out in 2010. Nikolaos, 2008. Metropolitan of Mesogaos Lavreotiki. The Greek Orthodox position on the ethics of assisted reproduction. Reprod. Biomed. Online 17 (Suppl. 3), 25–33. Nobelfo ¨rsamlingen, 2010. The Nobel Assembly at Karolinska Institutet. 2010. Advanced information. Human in vitro fertilization. Available from: . Pennings, G., 2008. Ethical issues of infertility treatment in developing countries. Hum. Reprod. 8, 15–20. Pope John Paul, I.I., 1980. Discourse to those taking part in the 81st Congress of the Italian Society of Internal Medicine and the 82nd
G Benagiano et al. Congress of the Italian Society of General Surgery. Acta Apostolicae Sedis. 72, 1126–1129. Porta-Ribera, R., Tre `mols, V., Munar-Mut, C., Boada-Pala `, M., Rı´os-Guillermo, J., Molina-Morales, V., 2009. Monitoring neurodevelopment in children born as a result of using assisted reproduction techniques. Rev. Neurol. 49, 463–466 (in Spanish). Schenker, J.G., 2007. Assisted reproductive technology in Israel. J. Obstet. Gynecol. Res. 33 (Suppl. 1), S51–S55. Schenker, J.G., 2008. The beginning of human life. Perspectives in Halakha (Jewish religious law). J. Assist. Reprod. Genet. 25, 271–276. Serour, G.I., 2002. Embryo Research. Ethical Implications in the Islamic World. ISESCO, Rabat (Morocco). Serour, G.I., 2008. Islamic perspectives in Human Reproduction. Reprod. Biomed. Online 17 (Suppl. 3), 34–38. Steptoe, P.C., Edwards, R.G., 1978. Birth after the reimplantation of a human embryo. Lancet 12 (2), 366. Tierling, S., Souren, N.Y., Gries, J., et al., 2010. Assisted reproductive technologies do not enhance the variability of DNA methylation imprints in human. J. Med. Genet. 47, 371–376. Van Steirteghem, A., Bonduelle, M., Devroey, P., Liebaers, I., 2002. Follow-up of children born after ICSI. Hum. Reprod. Update. 8, 111–116. Declaration: The authors report no financial or commercial conflicts of interest. Received 23 November 2010; refereed 12 January 2011; accepted 3 March 2011.
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ARTICLE
Robert G Edwards and the Roman Catholic Church Giuseppe Benagiano *, Sabina Carrara, Valentina Filippi Department of Gynaecology, Obstetrics and Urology, Sapienza, University of Rome, Italy * Corresponding author. E-mail address: [email protected] (G Benagiano). Giuseppe Benagiano, a Professor Emeritus at ‘la Sapienza’, University of Rome, where he became professor in 1980, acted as Director of First Institute of Obstetrics and Gynaecology during 1982–1993 and finally was Dean of Post-graduate School of Gynaecology and Obstetrics. He was nominated Director of Special Programme of Research in Human Reproduction of WHO in 1993 and became Director General of Istituto Superiore di Sanita in 1994. He studied at Karolinska Institute, Stockholm and Population Council, Rockefeller University. His longstanding interest is hormonal contraception; in addition, he pioneered the use of GnRH analogs for gynecological disorders of endocrine origin.
Abstract The Roman Catholic Church reacted negatively to the announcement that the Nobel Prize for Medicine had been awarded
to Robert G Edwards. Thirty-three years ago, Cardinal Albino Luciani, on the eve of his election to become Pope, stated that, whereas progress is certainly a beautiful thing, mankind has not always benefited from progress. Catholic criticism has raised seven points: (i) God wants human life to begin through the ‘conjugal act’ and not artificially; (ii) artificial interventions at the beginning of human life are dangerous and ethically unacceptable; (iii) limits can be imposed even upon an individual’s freedom to achieve a legitimate goal, such as having a child within marriage; (iv) the massive loss of preimplantation embryos characterizing IVF must be considered as a tragic loss of ‘nascent’ human persons; (v) Edwards bears a moral responsibility for all subsequent developments in assisted reproduction technology and for all ‘abuses’ made possible by IVF; (vi) there can be deleterious consequences for offspring of assisted reproduction technology; and (vii) Edwards’ discovery did not eliminate the causes of infertility. This article elaborates from the Roman Catholic perspective on each of these points, some of which are found to be more substantial than others. RBMOnline ª 2011, Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved. KEYWORDS: early embryo wastage, ethics of IVF, Robert G Edwards
Introduction On 14 October 2010, the Nobel Assembly at the Karolinska Institute in Stockholm announced that ‘The 2010 Nobel Prize in Physiology or Medicine is awarded to Dr. Robert G Edwards for the development of human in-vitro fertilization (IVF), a medical advance that represents a paradigm shift in the treatment of many types of infertility’ (Nobelfo ¨rsamlingen, 2010). The Roman Catholic Church reacted to the announcement with a series of declarations by some of its most influ-
ential officials and experts. First came a statement by Monsignor Ignacio Carrasco de Paula, the new President of the Pontifical Academy for Life; the prelate stated to the Italian ANSA News Agency (2010): ‘I believe that the selection of Robert Edwards is totally out of order.’ He went on explaining that he had no intention of negating Edwards’ scientific merits, although there were many reasons that made him perplexed about his choice for the Nobel Prize: ‘first of all, without Edwards there would not be ‘the oocyte market’ with its huge trade of millions of oocytes; second, without Edwards there would not be, all over the world, a
1472-6483/$ - see front matter ª 2011, Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.rbmo.2011.03.004
666 large number of freezers full of embryos, who – in the best case – are waiting to be transferred into a uterus and more probably will end-up abandoned or let die.’ He went on stating that ‘without Edwards we would not have the great state of confusion in the world of assisted reproduction with situations impossible to understand, like children born from foster [in Italian, ‘rented’] mothers’. Carrasco’s final point was: ‘I would say that, at the end of the day, Edwards did not resolve the problem of infertility, which is a serious problem, either from the point of view of pathology or that of epidemiology.’ He concluded that for a true resolution ‘we must wait until research finds another solution, among others more economical and therefore more accessible than in-vitro fertilization (IVF).’ Another Catholic voice expressing perplexity was that of the Catholic priest Roberto Colombo, Professor and Director of the Institute for the Study of Inherited Diseases at the Catholic University of the Sacred Heart in Rome, a member of the Italian National Committee on Bioethics and of the Pontifical Academy for Life. He stated (ANSA News Agency, 2010) that ‘although he recognized the scientific importance’ of Edwards’ discovery, ‘in-vitro fertilization raises serious ethical questions in terms of respect for the beginning of human life and for the dignity of human procreation.’ He went on to say: ‘not everything that is scientifically brilliant, or clinically possible, or legally permitted is licit and in itself devoid of ethical, familial and social questions.’ He then concluded: ‘Although many in these hours are stressing the success of techniques of medically-assisted procreation developed from Edwards’ work, their diffusion in every part of the world, and the large number of babies born through them, without subtracting anything to the scientific and clinical merits of the discovery that received the Nobel Prize, we cannot forget the even greater number of human individual lives, at the stage of embryo development that have been interrupted because of the experimental conditions of their in-vitro culture, of the selection practiced on them, and their non transfer [the Italian word used is ‘implant’] to the uterus.’ Colombo concluded: ‘The primacy of the protection and promotion of human life and of the dignity of the human person cannot be compared with scientific and technological progress, even that with the highest profile.’ Additional negative reactions came from Catholic organizations. The President of the International Federation of Catholic Physicians (FIAMC), Dr. Jose Maria Simon Castellvi, issued a statement denouncing: ‘As Catholics we believe in the absolute dignity of the human person, created in the image and likeness of God,’ and ‘that dignity exists from the earliest moment of the conception of the new human being and remains with them to their natural death.’ The statement went on decrying the use of millions of embryos, thus human beings, created and discarded ‘as experimental animals destined for destruction. This use of human embryos, has led to a culture where they are regarded as commodities rather than the precious individuals which they are’ (Mercopress, 2010). Finally, Catholic members of the European Parliament also criticized the choice of Robert Edwards. Carlo Casini, a prominent pro-life parliamentarian, stated: ‘The assignment to Professor Edwards of the Nobel Prize for science is a source of great pain, because it ignores the hundreds of million of human beings at the
G Benagiano et al. embryonic stage – children – of which in-vitro fertilization has deliberately caused the death all over the world’ (Casini, 2010). Criticism of IVF by prominent Roman Catholic officials is certainly not new and has been made since the first announcement of the birth of Louise Brown. During the days following the announcement in 1978, the then Cardinal Patriarch of Venice, Albino Luciani, granted an interview, some 2 weeks before the Conclave that would elect him Pope John Paul I. This interview was in press when Cardinal Luciani was elected Pope and the Editor decided it was his duty to stop the printing until he could get a formal authorization by the new Pope. Apparently, the Pontiff appreciated the Editor’s discrete approach and promised that he would discuss, among others, this very topic in an audience he was going to grant the journal’s Editorial Committee. As everyone knows, the Pope died prematurely after only 33 days in office. After a while, the Editor decided to publish the interview and the views of Pope John Paul I were made public (Luciani, 1978), although, at the time the publication was ignored by the media. Ironically, in that interview, the future Pope started by saying: ‘In this moment I am not speaking as a Bishop; rather, I am speaking as a journalist consulted by a fellow newsman on a matter as delicate as almost totally new. I put myself in the position of someone who waits what the true Church Magisterium would wish to say, after listening to the experts.’ We said ‘ironically’, because – within days – he would, as Pope, have a special role within the Magisterium he was referring to! Luciani went on by saying: ‘I wish to make four points’ and these will be fully detailed in the next paragraphs. From all these pronouncements certain basic principles came out, although with a different emphasis. The first and most important being that God wants human life to begin through the ‘conjugal act’ and not in an artificial way. Several additional major critiques have been made by Catholic experts against Edwards’ work: the second deals with the unethical and ‘dangerous nature’ of artificial interventions at the beginning of human life; a third stresses that limits can and should be imposed upon an individual’s own conscience and therefore to her/his freedom to achieve even a legitimate goal, such as having a child within marriage; a fourth stresses the massive loss of early, preimplantation embryos that characterizes IVF, a situation that the Church considers as a tragic loss of ‘nascent’ human persons; a fifth attributes to Edwards a moral responsibility for all subsequent developments and therefore for all ‘abuses’ made possible by IVF; a sixth – legitimate in the early days – feared deleterious consequences for offspring; and a seventh makes the point that his discovery did not eliminate the causes of infertility, nor did it solve the plight of most childless women. The lengthy quotations presented above provide ample proof of the magnitude and multiplicity of the criticism levered against Edwards’ work; under the circumstances, an in-depth analysis of all questions raised and of all implications stemming from them will be all but impossible. Nonetheless, this paper will try to analyze from the moral perspective of the Roman Catholic Church, each of these main points, bearing in mind that disagreement is going to continue between those who believe that a couple has an absolute right to have a child, no matter how and independently
Edwards and the Roman Catholic Church of whether the child is biologically theirs, and those who hold that children can morally be brought to life only within the bond of marriage and through natural intercourse. For this reason, the analysis will be limited to addressing each issue exclusively from the perspective of a believer who holds that God intervenes at or after each conception, infusing in every human being an immortal soul. Although it is not known when this happens, a theist outlook requires that human life be considered sacred and therefore be protected from its inception (Benagiano et al., 2011).
In God’s plan, human life can legitimately be initiated only through the natural conjugal act between spouses This argument goes to the heart of Edwards’ work, based on the process of initiating human life outside the female reproductive tract. Back in 1978, the future Pope John Paul I stated: ‘Coming now to the act itself and without reference to the parties’ good faith, the moral problem at stake here is whether extracorporeal fertilization in vitro, or in a vial, is licit. Pius XII, speaking about artificial fertilization within matrimony, made the following distinction: Is the technical intervention of the physician such as to facilitate the matrimonial act between the spouses? Or, does it help to obtain a child, continuing – somehow – an already-accomplished matrimonial act? In this case, there is no moral issue at stake and the intervention can be applied. What if the ‘artifice’ instead of helping or continuing the conjugal act, excludes and substitutes it? Then that intervention is not licit because God linked transmission of human life to conjugal sexuality. This is, more or less, Pius XII teaching; and I do not find valid arguments to dissociate myself from this norm, declaring permissible to separate the transmission of life from the conjugal act’ (Luciani, 1978). This concept was formalized many years later in an Instruction by the Congregation for the Doctrine of the Faith (known in the past as the Holy Office) issued in 1987–1988: ‘These techniques can enable man to ‘take in hand his own destiny’, but they also expose him ‘to the temptation to go beyond the limits of a reasonable dominion over nature’’ (Pope John Paul II, 1980). They might constitute progress in the service of man, but they also involve serious risks. Many people are therefore expressing an urgent appeal that in interventions on procreation the values and rights of the human person be safeguarded. The Instruction then clearly states: ‘From the moment of conception, the life of every human being is to be respected in an absolute way because man is the only creature on earth that God has ‘wished for himself’ and the spiritual soul of each man is ‘immediately created’ by God; his whole being bears the image of the Creator. Human life is sacred because from its beginning it involves ‘the creative action of God’ and it remains forever in a special relationship with its Creator, who is its sole end. God alone is the Lord of life from its beginning until its end: no one can, in any circumstance, claim for himself the right to destroy directly an innocent human being. Human procreation requires on the part of the spouses responsible collaboration with the fruitful love of God; the gift of human life must be actualized in marriage through the
667 specific and exclusive acts of husband and wife, in accordance with the laws inscribed in their persons and in their union’ (Congregation for the Doctrine of the Faith, 1988). Several Christian Orthodox Churches share the Catholic view. As an example, a document issued in 2006 by the Bioethics Committee of the Holy Synod of the Church of Greece states: ‘The way life begins is sacred: physiologically speaking, the exact moment of the beginning of life, within the context of physiology is unknown to man . . .’ At the same time, the Committee noted that: ‘Modern technology introduces us to the logic of sexual intercourse without reproduction and of reproduction without sexual intercourse. The dynamism of technology takes the beginning of life out of the warmth and darkness of the maternal body, out to the coolness and transparency of the test tube. . . . It abolishes the uniqueness of the spouse’s presence by substituting them with medical staff. . . . The child . . . is not directly conceived by his/her parents’ (Nikolaos, 2008). Christian believers within the Catholic and Orthodox traditions therefore enter this debate pointing out that from their perspective, the very moment God infused an immortal soul to Homo sapiens, or one of its predecessors, two dramatic facts occurred and forever changed our universe. On the one hand, the Creator who, according to physical, biological and evolutionary evidence, after the ‘big bang’ let His ‘Intelligent project’ move on through natural evolution (e.g. Collins, 2006), decided to intervene infusing an immortal soul in this new creature and guiding its progress. On the other hand, from the beginning of their appearance on Earth, these creatures started modifying natural evolution, beginning with agriculture, domestication of animals and continuing to our days with medical progress (mostly aimed at modifying the natural course of diseases), transgenic plants and animals and DNA research (also aimed at combating the natural course of negative inherited characteristics). Following this line of thoughts, there should be no reason why the Creator would place one and only one limit to human ingenuity. Obviously, whereas Catholic scientists can legitimately pose the question, they must then abide by the ruling of the Magisterium. Interestingly, this negative position is not shared by Islamic and Jewish theologians. In the case of Islam, initially reactions were negative. Although assisted reproduction is not mentioned in the primary sources of Shari’aa (the instructions that regulate everyday activity in the life of observant Muslims), initially patients and doctors felt that seeking assisted reproduction was a challenge to God’s will by trying to render barren women fertile. In addition, similar to the present position of the Catholic and Orthodox Churches, the idea of artificial handling of human gametes and embryos was rejected. It was only after prestigious scientific and religious bodies and organizations issued guidelines and these were adopted by medical councils and accepted by concerned authorities in different Muslim countries, that IVF became widely seen as an ethical solution to infertility. In Sunni Islam, IVF – excluding gamete donation and surrogacy – is accepted for married couples only. In the same circumstances, Shi’aa Islam permits surrogacy (Serour, 2008). Within the Jewish religion, the development of IVF made it necessary to consider the morality of conceiving a human being outside the womb and the fact that this was even
668 feasible has been considered as proof that embryos have not taken a different character by being created outside a woman’s body and that therefore the technique was permitted (Schenker, 2008). According to Rabbinical teaching, what is important is not where conception occurs, but whether conception is the consequence of the encounter between the gametes of the spouses, based on the commandment of procreation stated in the Bible (Genesis 1:18). This is why, the Jewish majority’s religious point of view, as formulated by the chief Rabbi of Israel supports IVF/embryo transfer (Schenker, 2007). It is important to stress that the issue of legitimacy of interventions at the beginning of human life, is precisely where the proponents of IVF believe that – to use the words of Jacques Cohen, the Chief Editor of Reproductive BioMedicine Online – ‘Edwards is our Galileo’, the one who has opened the way to a Copernican revolution in our approach to reproduction. This position has been echoed by secular philosophers (Benagiano et al., 2011).
The sacred nature of human life and the moral imperative to protect it from its inception The position of the Roman Catholic and Greek Orthodox Churches is unambiguous also on this point. As already mentioned, the 1987–1988 Instruction by the Congregation for the Doctrine of the Faith mandates that ‘nascent’ human life be given absolute protection (Congregation for the Doctrine of the Faith, 1988). This teaching has been repeated and reinforced 20 years later by the Congregation, specifically addressing the issue of early embryonic loss (Congregation for the Doctrine of the Faith, 2008): ‘It should be recognized, however, that given the proportion between the total number of embryos produced and those eventually born, the number of embryos sacrificed is extremely high. These losses are accepted by the practitioners of IVF as the price to be paid for positive results. In reality, it is deeply disturbing that research in this area aims principally at obtaining better results in terms of the percentage of babies born to women who begin the process, but does not manifest a concrete interest in the right to life of each individual embryo. It is often objected that the loss of embryos is, in the majority of cases, unintentional or that it happens truly against the will of the parents and physicians. They say that it is a question of risks which are not all that different from those in natural procreation; to seek to generate new life without running any risks would in practice mean doing nothing to transmit it. It is true that not all the losses of embryos in the process of IVF have the same relationship to the will of those involved in the procedure. But it is also true that in many cases the abandonment, destruction and loss of embryos are foreseen and willed.’ Under the circumstances, the Congregation could only repeat that IVF practices cannot be accepted. Yet, in spite of this repeated formal pronouncement that leaves no space for compromise, the Catholic Church left the door open to one form of assisted reproduction, the all-but-abandoned gamete intra-Fallopian transfer (GIFT) (e.g. Braeckmans et al., 1987) and one might argue that at least one development stemming from Edwards’ work could be judged without a negative eye.
G Benagiano et al. The Catholic position is echoed in the already-quoted declaration by the Bioethics Committee of the Synod of the Church of Greece: ‘The rights of an embryo emerge from the fact that the embryo is a person under development; it is an entity which depends on and results from the will of third persons and is unable to take care of and defends itself’ (Nikolaos, 2008). To strengthen the moral imperative to defend ‘nascent’ human life, during the second half of the 20th century the Catholic Church has placed the age-old debate over the moment of ensoulment (delayed animation versus immediate animation) – so to speak – on the back burner, by shifting emphasis from theology to pastoral care (Benagiano and Mori, 2009). Theology cannot resolve the issue of when ensoulment takes place and therefore when a ‘human life-form’ becomes a ‘human person’ through God’s direct intervention. Therefore, the supreme value of the defence of life from its inception can be better served by stating positively that, after fertilization the early human embryo must be protected ‘as a person’ or, according to Ford (2002, 2008), as a ‘potential human person.’ Here again, the Catholic and Orthodox position is not shared by Islamic and Jewish theologians. In the Muslim World, prevention and treatment of infertility are of particular significance because the social status of women, their dignity and self-esteem are closely related to their procreation potential, both for the family and society as a whole (Serour, 2008). At the same time, Islamic teaching, on the issue of the status of early human embryonic life, stems directly from the Holy Quran itself where it is explained that the development of intrauterine life advances step by step from a clot to a lump of flesh then boned flesh and finally a fully grown infant (Sura El Hag 22:5; Sura El Mo ´menon 23:14). Therefore, according to Islamic theology, ensoulment of the fetus occurs after 120 days following fertilization, although some authorities consider it to occur as early as 42 days post-fertilization (Hadith Sharif). Recently, even this new earlier threshold has been brought back to 14 days after conception, because recent discoveries in human embryology have established that individuality of the new being is achieved at that stage (Serour, 2002). Jewish interpretation of when human life begins is extracted predominantly from Halachic (Jewish Religious Law) sources, because the Bible does not make any direct references to when exactly a new life begins. While the Talmud gives the full status of humanness to a child at birth, rabbinical writings have slightly extended the acquisition of humanness for full-term infants to the 13th day of extrauterine life. The Babylonian Talmud (Yevamot 69b) states that: ‘the embryo is considered to be mere water until the fortieth day.’ Afterwards, it is considered ‘subhuman’ until birth (Schenker, 2008).
The massive wastage of embryos runs contrary to the stated absolute value of human life The denunciation of the ‘massive loss’ of human embryos has been made by Catholic experts more and more forcefully in recent years. If a human embryo has to be considered ‘as a person’ from the moment of conception, it inevitably follows that IVF raises additional ethical
Edwards and the Roman Catholic Church problems when supernumerary embryos are created and then not transferred (whether cryopreserved or not). This is the reason why the Catholic Church threw its full support behind the Italian IVF Law, that makes it mandatory to transfer every embryo produced during an IVF cycle. Whereas the Church does not approve of IVF in any form (with the already-mentioned possible exception of the GIFT procedure), it considers that in a multicultural society, the procedure should not be outright banned; rather, it should be carried out without any loss of early embryos (Benagiano and Gianaroli, 2004). This is because: ‘There is no justification for the reductionism that sees human embryos as no more than genetic products, devoid of moral significance and value. From a theistic perspective, the fruit of human generation in the early embryo has moral significance and a claim to unconditioned moral respect.’ In this view, the deliberate destruction of a human embryo is a serious moral offence against the basic good of human life (Ford, 2002). When it was pointed out that massive early embryo wastage is a natural and physiological phenomenon that cannot be avoided (Benagiano et al., 2010), theists have replied that there is no moral problem with people dying at any stage of life – provided nobody has caused death deliberately, or by lack of due care in the family context, or in a professional medical situation. On the one hand, modern science and medicine enable more lives to be saved before and after birth; on the other, believers in God (and more specifically Christian believers in God’s divine revelation in the historical Jesus Christ) do not accept that death is the end of the entire person. For them, the human soul, unlike that of animals, is spiritual, i.e. immaterial and is not liable to corruption when human individuals die. Catholic teaching holds that the souls of deceased persons do not cease to exist: being immaterial, they cannot corrupt as bodies do. In this perspective, it does not matter how early a human being ceases to exist after conception (Benagiano et al., 2011). Clearly, those who believe that matter and material energy alone exist in this world simply cannot accept the idea that the spiritual soul of a deceased human individual could survive and eventually be united again with a renewed body to form the same living human person as one entity. And even if they might accept it, they would argue that in the event of early embryos or, a fortiori, in the event of aneuploid or polyploid embryos, blighted ova and an embryonic vesicular moles, there would be no person in the first place with which to be reunited (Benagiano et al., 2011). Therefore, most non-believers in God, in spiritual souls or in any immaterial beings would find the above discourse difficult or problematic to say the least. Some might find it out of touch with reality or even bordering on the ridiculous (Mori, 1996, 1998a,b).
The legitimate goal of having a child within marriage is not absolute and ethical limitations should be imposed The future Pope John Paul I in his interview (Luciani, 1978) said: ‘The press, in many countries is sending congratulations to the family and best wishes to the child. Following God who wants and loves human life, I am also sending my most cordial wishes to the baby girl. With regard to her
669 parents, I have no right to condemn them: subjectively, if they acted with right intentions and in good faith, they may even have a great merit in front of God for their decision and for what they asked physicians to execute. We agree that individual conscience must always be followed, both when it commands and when it forbids; at the same time an individual must make an effort to have a well formed conscience. Indeed, conscience does not have the role of creating the law. It has two separate functions: to inform itself about what God’s law says; and to judge whether there is synchrony between this law and a given action by us. In other words conscience must command man, not obey to man.’ He went on saying: ‘I read in the press – ‘‘it is ridiculous to pose moral problems to those availing themselves of magnificent scientific discoveries. And, on top of it, there are the rights of a free individual conscience.’’ Very well, but ethics does not entertain scientific discoveries, it deals with human actions through which persons can utilize for good or bad scientific discoveries.’ This position is still considered valid by the Catholic Church, which refuses to accept that there is an ‘unlimited right’ to have a child.
Edwards bears moral responsibility for all subsequent developments in IVF An indirect response to this argument comes from the Catholic geneticist Bruno Dalla Piccola (2010), President of the most influential Italian pro-life organization, ‘Scienza e Vita’ (Science and Life), who acknowledged that ‘Edwards has had a major influence in the history of medicine’, adding: ‘having made this premise, today, years later we can say that in the practical applications, we are far away from the original spirit of his research. At the beginning the issue was that of overcoming mechanical problems preventing the encounter between the oocyte and the spermatozoa’. Dalla Piccola believes that ‘over the years these techniques have become an abuse and a form of reproductive ‘fury’ [accanimento] thanks to a dramatic economic pressure’, but he said nothing about holding Edwards responsible for every later ‘abuse’ committed. In all honesty, we believe that the argument of his personal responsibility for every subsequent development (irrespective of whether they are considered positive or negative) cannot be put forward. First of all, we must bear in mind that Louse Brown was conceived with one oocyte obtained from a natural cycle and therefore, in this first famous case, there was no embryo wastage whatsoever (Steptoe and Edwards, 1978). In addition, to consider Robert Edwards morally responsible for all subsequent ‘abuses’ perpetrated by those who applied and expanded his technique is like considering Enrico Fermi responsible for the massacres of Hiroshima and Nagasaki.
There are inherent dangers in IVF and infants born from the technique may be exposed to unknown risks The issue of possible risks for offspring of IVF was the subject of strong debate from the early days of Edwards’ research. In the memoir written with Patrick Steptoe (Edwards and Steptoe, 1980), he mentions an episode that
670 is highly descriptive of a view held by many in the 1970s, namely that his experiments would lead to the production of monstrous creatures. At a panel discussion named ‘Fabricated babies: the ethics of the new technology in beginning life’, during a conference in the USA in 1971, famous scientists rose to speak against the work conducted by Edwards and Steptoe. Paul Ramsey, a theologian from Princeton University, denounced their work in very strong terms. As Edwards recounted in the book: ‘He doubted that our patients had their fully understanding consent. We ignored the sanctity of life. We carried out immoral experiments on the unborn. Our work was, he thundered ‘unethical medical experimentation on possible future beings and therefore it is subject to absolute moral prohibition’. Even more astounding was the reaction of James Watson, the scientist who received the Nobel Prize for the discovery of the DNA double helix. Addressing Edwards he stated: ‘You can go ahead if you accept the necessity of infanticide. There are going to be a lot of mistakes. What are you going to do with the mistakes? We have to think about some things we refuse to think about.’ Years later, the future Pope John Paul I used milder words, although, clearly, this was after the birth of the first IVF baby (Luciani, 1978): ‘I share only in part the enthusiasm of those praising the progress of science and technology after the birth of the English baby girl. Progress is certainly a beautiful thing, but mankind has not benefited from every progress advancement. ABC (Atomic, Bacteriological and Chemical) armaments have been ‘progress’, but, at the same time, a disaster for humanity. Whereas the possibility to have a baby ‘‘in vitro’’ does not cause disasters, it does carry major risks. For instance, natural fecundity carries sometimes the risk of malformations; how do we know that artificial fecundity will not carry greater risk of abnormalities? If so, confronted with these problems, wouldn’t the scientist look as the ‘‘sorcerer’s apprentice’’ unleashing formidable forces, without being able to rein them in? Another example: given today’s crave for money and moral unscrupulousness, should not we be afraid that we will see the birth of a new industry, the ‘‘children’s factory’’, perhaps for those who do not or cannot contract a valid marriage? If this happened, wouldn’t the family and society as a whole be in regress, rather than in progress?’ Fear of adverse effects on offspring was only natural during the years preceding Louise Brown’s birth or immediately afterwards; today, however, data have been accumulated indicating that IVF, in its many forms, does not carry unacceptable risks of increased anomalies in children born from the procedures. It is beyond the scope of this paper to discuss the subject and we will limit ourselves to briefly reporting that, in a major survey, Van Steirteghem et al. (2002) pointed out a number of factors that may hamper any comparison of outcome of children born after assisted reproductive technology and those naturally conceived. First of all, the differences in the characteristics of infertile patients such as age and genetic risks. In addition, the type of neonatal surveillance protocol, the number of individuals lost to follow-up, the size of the cohort study and the lack of standardization in defining, for example, major anomalies are all factors complicating true comparisons. Also Ludwig and Diedrich (2002) believe that molecular biological studies support the idea that these risks are not related to the
G Benagiano et al. technique used, but to parental background factors; they point out that data from surrogate motherhood also demonstrate that there the risk is lower as compared with pregnancies from IVF mothers, who carry their own child to birth. At any rate, a wealth of information is today available on children born after assisted reproduction technology. Recent studies indicate that assisted reproduction does not enhance the variability of DNA methylation imprints (Tierling et al., 2010); in addition, the health and neurodevelopment of infants from IVF are similar to those of the general population (Porta-Ribera et al., 2009) and these children do not suffer poorer cognitive development at 3 years (Carson et al., 2010). A different picture came out in the review of the literature conducted by Van Steirteghem et al. (2002) of the limited available data on fetal karyotypes after the technique known as intra-cytoplasmic sperm injection (ICSI). This revealed that in children born after ICSI there is: (i) a slight but significant increase in de-novo sex chromosomal aneuploidy (0.6% instead of 0.2%) and structural autosomal abnormalities (0.4% instead of 0.07%); and (ii) an increased number of inherited (mostly from the infertile father) structural aberrations. Furthermore, in 8319 live-born ICSI children, the mean percentage not originating from singleton pregnancies was 40%, with a range of 32.6–60.8%. Most multiples are twins, but there are also 4.4% triplets (in one survey 13.2%). They point out that this substantial increase in multiple pregnancies must be considered the most important complication of assisted reproduction technology.
IVF does not eliminate causes of infertility, nor does it solve the plight of most childless women Many have argued that infertility is ‘not a disease’ (although it is often the consequence of a disease or a dysfunction). As such, in many infertile women there is no disease to treat; rather there is a need to make conception possible. In this sense, the procedure first applied by Edwards and Steptoe did resolve the problem allowing a woman to conceive and carry her baby to term. It is interesting that in the already-mentioned book (Edwards and Steptoe, 1980) Edwards mentions the opposition to his work by Leon Kass of the US Academy of Sciences, an opposition based on the argument that his work was not therapeutic – women would still be infertile even if the technique successfully produced live children after transferring embryos in them. Edwards commented: ‘That argument surely was scarcely credible. So much medical treatment is directed towards replacing a deficiency rather than producing a cure. Consider for instance the life-saving therapy of insulin for diabetes. Or, for that matter, the value of false teeth and spectacles!.’ More complex is the issue of availability of infertility treatment, an issue that must be considered within the context of inequalities in access to health care. Even the European Union Commission (EC) has acknowledged that gender-based inequalities are present in health care and in long-term care, as well as in health outcomes, within the borders of the European Union (European Commission,
Edwards and the Roman Catholic Church 2010). As pointed out by the EC, what needs to be borne in mind, being very relevant when discussing access to assisted reproduction technology, is the fact that women and men are confronted with gender-specific health risks and diseases which need to be adequately addressed in medical research and health services. Therefore, those stating that IVF cannot, because of its cost and complexity, be practically applied to the majority of couples in the developing world have a point, since availability of assisted reproduction technology is still limited to a minority of women in a minority of countries. Having said this, it is equally true that efforts are being made by many to increase availability and decrease costs; these efforts are important because in a number of countries childlessness is a real curse and infertile women can be divorced simply on the ground that they cannot provide an heir to their families. Tragically, this curse is much more serious in the developing world, where access to assisted reproduction technology is problematic, to say the least. In addition to the personal grief and the moral suffering it causes, the inability to have children, especially in poor communities in the developing world, can produce broader problems, particularly for women; it creates a social stigma, economic hardship, social isolation and even violence. In some societies, motherhood is the only way for women to improve their status within the family and the community. On a practical level, many families in developing countries depend on children for economic survival. For these reasons, the academic discussion whether ‘infertility is a disease’ becomes irrelevant for two reasons: first, infertility is always the consequence of an abnormal, often pathological situation (although, sometimes ‘unexplained’); second, for sure it is a social and public health issue as well as an individual problem. Finally, over the last decades, people from Western countries have cultivated the belief that overpopulation, not infertility, is the major problem of developing countries, creating a practical, but important barrier to even consider infertility treatment in resource-poor countries. What this approach fails to take into consideration is the fact that we are dealing with the personal suffering of individuals, not with global solutions, and we cannot avoid helping these individuals. Clearly, infertility treatment in resource-poor countries can only be considered when two conditions are fulfilled: (i) a minimal level of political stability and a minimal basic structure of healthcare provisions; and (ii) we should be not only discussing high technological interventions like IVF, but including other interventions of a lower technical nature (Pennings, 2008). In summary, the Catholic Church is correct in supporting the right of women to have access to infertility treatment, provided this treatment meets clear ethical standards.
Conclusions We hope to have shown how the critical position of the Catholic and Orthodox Churches towards Robert Edwards’ scientific achievements is diversified and nuanced. The fundamental point at stake for the Churches is respect for human life from its inception and the requirement that a new human life must begin only through natural means.
671 We sincerely hope that those in disagreement with the Churches’ position will respond with valid arguments, so that a constructive dialogue can be established on an issue of fundamental importance for the future of the human species.
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