The Ethics of IVF
A Probabilistic Natural Law Semi-Contrarian Case
There remains a segment of the pro-life movement that has a purity-spiraling element to it, much too concerned with do-gooding in other people’s business at a very low return on political capital, particularly in blue areas of the country now that the issue has been de-federalized. I suppose, as Trump implied recently, there might be a fundraising motive for expanding the scope of the movement after achieving the major policy goal of overturning Roe. Like Trump, who also discovered the internal contradictions of the pro-life movement when he naively agreed early in his 2015 candidacy that murder should be punished, something feels off to me about aspects of their moral reasoning.
I’m just not as excited about the issue now that conservative polities are free to enforce their own laws against it. If others who don’t share our fundamental values are committing generational suicide, is it our responsibility to stop them, or spend capital, political or otherwise, to force people against their will not to kill their own children? As I half-joked to a conservative friend, we don’t see the Israelites protesting outside the altars of Baal as the Canaanites burned their infants in the fire; God had a rather different solution in mind.
The sad truth appears to be that outside of the Deep South, it’s really important to voters that they retain the option to murder their unborn children. Contra Russell Moore, it turns out “cultural Christianity” is an epiphenomenon of actual Christianity which brings real tangible benefits to the most vulnerable.
More recently, however, in talking to my kids about what they’re hearing from conservative media, I’ve come across rhetoric from prominent pro-life commentators equating the use of IVF to abortion, and the Alabama Supreme Court, in a particularly impolitic self-own, recently ruled in a manner that makes IVF too risky for providers to operate. So despite being more practically anti-abortion that most pro-lifers — in that I think the murder is murder and all parties involved should be prosecuted criminally — I find myself very averse to this latest anti-IVF expansion of the agenda.
Personally, my family has never had to make use of these technologies, so hopefully that helps me make a non-emotional argument about it, as I don’t personally have a dog in the fight. However, this matters to me because such good fortune is not guaranteed to others. For Christians in particular — who are more vulnerable to manipulation from pietists in the church — it bothers me that emotional arguments from public activists might guilt them into not having their own genetic children using reproductive assistance technologies, if that were necessary.
One of the reasons I write is to hopefully provide a perspective from someone who doesn’t write or raise money for a living, has some real life experience, and being liberated decades ago from my corporate job, to speak for the reasonable majority of productive people who don’t have time to argue on the Internet. In addition, I have several friends who have used IVF to form or expand their own families, all good people who deserve more than quietly ignoring the critics.
Unfortunately, the Internet attention economy rewards people who take extreme positions, and a particular schtick of Christian influencers is to take a bold stand on some side issue, whether IVF or the mechanics of predestination, to show what a big, tough conservative they are. Conveniently, these are always secondary issues that won’t get them cancelled in a direct confrontation with the culture at large.
The Disgust Factor
In talking to one of my most trusted friends about this, it was pointed out to me that part of the new opposition to IVF may be related to healthy disgust instincts.
First, some providers are known to engage in “fetal reduction,” i.e. selective abortion when the techniques work too well and result in multiple children in the womb1. The trend of practices in the industry has been towards minimizing this outcome, as better technology allows greater success of single embryo transfer, which is now recognized as the best option for both mother and child. That is, the risk of a multiple pregnancy carried to term now exceeds any benefit from transferring multiple embryos to better guarantee at least one live birth.
Second, when combined with surrogacy, IVF is now associated with the formation of “Frankenstein families,” where children are ordered up like consumption items, often in situations where the child will be deprived of either a mother or father. Surrogacy, however, presents its own, separate ethical issues2 that are not logically related to IVF, which normally helps a child’s own genetic mother become pregnant.
Third, the cultural prominence of IVF has created an unhealthy perception about its capabilities and risks. First, the drugs and procedures involved present uncommon but significant risks to health compared to natural conception. Further, It deceives young women into delaying childbearing without fully considering its relatively poor success rates in older women. Egg and embryo freezing is no substitute for prime natural fertility, which begins to decline at age 27, and precipitously after 30, particularly for women who have not conceived previously.
Most famously, a young woman, Brigitte Adams, who was featured on the cover of Businessweek for freezing her eggs to avoid dampening her career ambitions, was tragically unable to successfully use them when she thought she was ready for motherhood. She’s undoubtedly an extremely talented person and the loss of her genes, and that of talented women like her, due to misperceptions of the efficacy of IVF is a huge loss for society3. All advertisements for IVF should come with a Surgeon General’s warning: “IVF PRESENTS SIGNIFICANT HEALTH RISKS, DOES NOT RESULT IN LIVE BIRTHS FOR MOST PATIENTS, AND SHOULD NOT BE USED TO DELAY NATURAL CONCEPTION.”
So perhaps some of the newfound right-wing antipathy is IVF is understandable as a healthy instinct. But just as the fact of alcohol abuse doesn’t justify prohibition, the ethical status of IVF demands a more nuanced analysis.
IVF Ethics
At minimum, it seems like people ought to be very humble in sharing an anti-IVF view, because they are attacking the only means by which some people are able to have children, and as this is often a private decision, one has no idea who has used it. It’s incredibly divisive to take a strong position if one allows for any ambiguity whatsoever. And from what I can tell, there is not only ambiguity but also a good deal of ignorance about the biology involved.
First, let’s define our terms. While IVF is part of a suite of reproductive assistance technologies, the objection seems to be to IVF specifically, which we can define as laboratory procedures to gather eggs and sperm from Mom and Dad, or donor gametes if necessary, and have fertilization occur outside the body in a glass dish (the vitro, hence IVF). The embryo then develops for a few days as it would in the fallopian tube, and at the optimal time, artificially deposited into Mom’s uterus for implantation and further development to live birth. I’ll make a number of reasonable conjectures to speed our argument along:
The prominent, credible critics of IVF do not object to medically-enhanced fertility technology in general. Few would object to the use of drugs like Clomid to enhance gamete production, for example.
A few critics focus on the removal of fertilization from its natural setting as being itself inherently wrong. Given any medical intervention is unnatural, I cannot imagine why this single function ought to be exempt from the general acceptance that medical interventions are permissible to prolong life and health. Some might take issue with the latter, that carrying one’s own genetic child does not inherently promote life and health, but such an argument would also preclude less invasive reproductive technologies as well, unless again the objection is solely to the setting of fertilization. I will not further address either of these arguments directly as credible. Thus:
The main credible objection to IVF seems to be the loss of embryos the process can entail. My further arguments will address this specifically.
Let’s reduce the argument to its essence. There are life-sensitive IVF providers who only fertilize 2 eggs at a time and, regardless of viability, deposit them into the uterus for hopeful implantation in a patient fully prepared to carry twins if both are successful. Unfortunately, it rarely works out this way. Often, multiple pairs must be deposited, and often only one successfully implants. The IVF critic can then say that since the process often results in the death of an embryo, and no procedure can guarantee a successful result for all embryos, IVF is inherently an abortive procedure and thus akin to abortion.
The Personhood of Fertilized Eggs
The language surrounding life issues makes certain assumptions about the personhood of fertilized eggs. It seems that the movement has reacted to Leftist enthusiasm for baby-killing by defaulting to the opposite view, which is that life must begin at the earliest possible point when a human being is first uniquely conceived. However, it must be admitted that IVF critics have no objective basis for believing this other than their own interpretation of natural revelation via scientific advancements in our understanding of gestation in the 20th century.
In the medieval common law, harm to a unborn baby was considered murder only after the “quickening,” that is when the mother could detect the baby’s movements, and many assumed this threshold was when the soul entered the baby’s body and he or she became a unique person. Of course, we now know that fetal movements begin much earlier and that there is no such discrete point of development, as the nervous system differentiates continuously after implantation. We rightly used natural revelation to adjust our view of the personhood of unborn children to a much earlier point.
Part of the confusion on this issue arises from imprecise terms. A fertilized egg is clearly human, but so are any other tissues, as most cells carry the entire genome. If I donate blood, my donated tissue is human and has my unique DNA profile, but enjoys no human rights since it does not contain a soul, thus it is not a crime if it is disposed of for some reason or another, or bought and sold like a commodity, which is indeed the model of most blood banks. I can reasonably assume it has no soul because my continuous experience of my consciousness is not interrupted by its departure, and by definition souls are unitary, what theologians and philosophers call a monad.
The key question, then, is when developing embryos acquire the souls that make them uniquely human. There is no logical reason this must be coincident with the formation of a unique DNA profile at fertilization, though most agree this is the earliest point it could occur. This also must be an opinion based on natural revelation, because while historical natural law does inherently recognize the personhood of children before birth, it is silent as to when that personhood is acquired. Some resolve this by assuming it is the earliest possible point, fertilization, to provide maximum protection for life, which is indeed how many people handle this ethically.
However, such an opinion was effectively moot for most of human history. Since the technology to mechanically abort children was and is still fairly gross in scale, in no case was an abortion happening before any reasonable point where one could make a case that the baby wasn’t a unique person. Babies have heartbeats and voluntary movements weeks before it’s large enough to be mechanically aborted via standard surgical techniques. Thus, banning nearly all abortions remains the ethically consistent moral choice, and further since the intent of almost any kind of abortion4 is to disrupt a state of health and the normal operation of the human body to create new life, which is fundamentally perverse, such a ban is justified even if technology allowed for abortions prior to the embryo’s theoretical ensoulment5.
Reproductive assistance technologies like IVF, on the other hand, are medical interventions with the intention to restore a state of health — the ability to produce one’s own natural children6 — to a couple’s reproductive capacity. And we recognize, in other contexts, that the intent of a medical procedure matters. Breast augmentation is covered by insurance to restore a cancer patient’s amputated tissue, but is otherwise an out-of-pocket elective procedure, a recognition that restoring a state of health, to the extent technology allows, is part of what insurance must cover, but cosmetic preferences are not. We recognize the right generally of patients to risk their lives with potentially life-saving surgeries, and critically, for others to make that decision for patients who are incapacitated. We also allow risking of life for quality-of-life enhancements; if the technology existed, few would condemn a disabled person in a wheelchair from risking a 10% chance of death in surgery to walk again.
In most IVF situations, the intent is to create new life when there is no other alternative. This good intention, in my view, allows us to more carefully question the knee-jerk sentiment that ensoulment and personhood happen at fertilization. When a technology offers an unmitigated good — a precious baby that would otherwise not exist — as its result, it bears a more careful analysis of its supposed moral cost.
Risk and Fertilized Eggs
We can begin the weaker form of the argument by granting the assumption that fertilized eggs are persons with souls. The question then becomes: just as consent can be given by next of kin for incapacitated patients to undergo risky surgeries to save or improve life, is it permissible for parents to make the same decision, the risk of life, to enable life to come into existence? These are somewhat different questions. One involves risking a life already in existence to save it, whereas the other involves risking lives not yet in existence to enable lives to exist that would never exist otherwise. It is not obvious to me that these questions have different answers.
As referenced earlier, one form of life-sensitive IVF involves harvesting gametes, fertilizing exactly two of them in vitro, then injecting both into the mother’s womb. Much of the time, only one will successfully implant, but if both do the mother will carry twins. Unless one holds a superstitious view of the site of fertilization — that somehow a kidney transplant is natural enough to be medically permissible but fertilization in a dish versus the uterus is not — the only rational objection here is the risk to the embryos, that one or both might die in the procedure.
The problem with this objection is that natural fertilization presents hazards that are far from negligible. Depending on the study, it is estimated that the normal, healthy operation of a woman’s body results in anywhere from 40-60% of fertilized eggs not successfully implanting. Many simply die due to bad timing, fertilized too late in the cycle and washed out by normal menses; this timing issue is the principle by which popular fertility-tracking apps operate. And in populations with fertility problems, the loss rate of embryos can be much higher7. Thus, in situations where all fertilized eggs are given a chance to implant, the risk to those embryos is not materially different than what would occur naturally anyway.
The medical fact of natural embryo death, however, provides additional information from the Book of Nature. If the female body is designed, in its normal and healthy operation, to routinely dispose of fertilized eggs due to mere timing issues in a woman’s cycle, it seems unlikely that a benevolent designer would engineer it this way if fertilized eggs were persons with souls.
One could argue here that embryo death is not a sufficient argument to demonstrate this, as we admit that children who are miscarried, or die in childhood, have souls. However, it’s important to distinguish between states of pathology — like miscarriage and childhood death — that are unfortunate parts of a fallen world and the normal, healthy operation of a woman’s cycle. It seems unlikely that the default, healthy design of human life, in fact the only mechanism in the universe that creates the conditions for new eternal souls, would have as part of its fundamental design the haphazard death of them!
If we grant this, we do not have to further consider ethical issues with IVF or decide when, technically, the soul enters the body, but rather rely on natural revelation to guide us, arriving at a simple heuristic for when life ought to be absolutely protected: the point where the healthy, normal operation of the human body results in a live birth. That point is implantation, not fertilization.
A useful analogy might be to the world of computers. A fertilized egg is software, a set of instructions for creating a unique potential human. The uterus is the hardware that provides the only setting where those instructions can be successfully executed to create a unique human. Their union is the logical beginning of human life. All upstream of this union is only potential life, and all downstream normally operates towards its development. Seen this way, IVF is in fact the opposite of abortion, not its analog. Abortion seeks to terminate the mother-child union, whereas IVF enables it where it cannot happen naturally.
The Cloning Hypothetical
Children of the 90s may remember the saga of Dolly the Sheep, the first cloned mammal. Since that time, cloning has expanded to other mammalian species, including for-profit cloners of pets. As far as we know, due to international agreements and perhaps technical difficulties, humans have not yet been cloned. However, it may have been done in secret and there’s no particular reason we should expect it to be scientifically impossible.
What interests me here is the process of cloning, where the least specialized adult cell types most similar to embryos — in Dolly’s case mammary cells, hence her name borrowed from Dolly Parton — are subjected to a process of chemical baths to coax the gene expression of the target cell into that of the generalist single-celled embryo; since almost every adult cell has the complete DNA of the animal, all information necessary for cloning theoretically exists in each of those cells.
Now let’s say an eccentric tech billionaire decides he wishes to clone himself. There are many reasons this would be morally problematic, but he does it anyway. Stem cells are harvested painfully from his bone marrow and subjected to the same coaxing chemicals to produce a viable embryo. However, this embryo is not the result of a union between sperm and egg, but rather is a modified adult cell that is capable of being implanted and developing into a full term child. Let’s say the billionaire created ten of these, cells that began as adult stem cells inside his body and now through chemical manipulation have the properties of a fertilized egg.
Do these embryos enjoy a right to life, that is, are they persons? It seems unlikely. One might object that these do not, since they are clones, not natural embryos, but this seems like a distinction without a difference. Natural human cloning already spontaneously occurs with identical twins, which means not all humans are the direct result of sexual reproduction, and no one questions their separate and independent personhood. Both the spontaneous and artificial possibility of cloning suggests that embryos before implantation are not yet sufficiently fixed in their destiny to constitute a person.
Computing the Probabilities
I tend to annoy some because I try to think in probabilistic continuities rather than fixed categories. This is not because I believe fixed categories of morality don’t exist, but rather that, lacking omniscience, it’s appropriate when answers aren’t obvious. For a lot of common questions, for example the morality of murder or non-reproductive paraphilias, the testimony of natural law is so strong that continuous probabilities collapse into certainty with an infinitesimal p-value for the null hypothesis. IVF strikes me as a non-obvious ethical question where public activists ought to be a lot less confident.
If I am 75% confident that fertilized eggs are not yet human persons with souls, and 90% confident that if they were persons then it would be ethically permissible to risk life to enable life, then my overall confidence in the permissibility of IVF is 0.75 + (0.9*0.25) = 97.5%. I know many find confidence intervals for moral categories uncomfortable, but it seems to me people ought to be a lot less confident in exceptional, non-obvious situations. All of us have enough obvious moral failings to work on without getting tied up in knots, or trying to tie other people up in knots, about the corner cases.
Given how many people have used the technology to produce their own beautiful natural children, it feels both rude and presumptuous to speak against it, when the moral categories are not obvious. And when moral choices are not obvious, and lead to good outcomes without observable suffering, we ought to leave it to people’s liberty.
Other Ethical Questions
If the personhood of pre-implantation embryos is subject to moral liberty, other ethical questions arise. The first is that morning-after contraception8 becomes arguably morally permissible. The second is that embryo selection, sometimes labeled by pro-life activists by the scare word “eugenics9,” is also arguably permissible.
The key question to parsing these issues is whether one is certain that pre-implanted embryos are not yet persons. If so, either of these would be permitted. However, I do not think one must go this far to allow IVF. As discussed earlier, one could affirm that embryos are persons but still allow for IVF because its intent is to create life, no different than the risk in a surgery that would improve quality of life but presents a non-negligible possibility of death.
The second question of eugenics is more interesting. Technology is now available to do full-genome sequencing of IVF embryos before implantation. Most traits people care about, like height or IQ, involve the interaction many different genes, unlike the simple Mendelian genetics most of us learned in high school biology. These traits are associated with statistical calculations called polygenic scores that have been measured at a population level for their association with desired or undesired traits, like propensity to develop mental illness.
I am a bit skeptical that this will work with present technology to create superhuman babies. First, regression to the mean is so powerful that if two parents with an average 145 IQ selected the best of 15 embryos, the average IQ of that embryo would be 143, still lower than the parents. Even selecting from 1,000 embryos, the baby would only be 2-3 IQ points higher than the parents. This doesn’t even consider measurement error from our relatively poor understanding of the full genome, as polygenic scores, while sufficient to show genetic influence for these traits across large samples, will naturally have a much wider confidence interval in predicting the traits of an individual because they are based on limited samples of SNPs.
Further, this assumes that people who could otherwise naturally reproduce will instead use IVF to optimize their children’s genetics. However, this may not be wise, with studies showing children conceived by IVF having a higher incident of heart defects, and the hormonal treatments that enable IVF have rare but serious side effects for some mothers. It’s not high enough to make IVF inherently dangerous or to persuade anyone to avoid it if it’s necessary, but more likely than not, there are benefits to natural conception that exceed any theoretical benefit of genetic selection through elective IVF. Biology is simply more complex than we understand and like the eventual finding that breastmilk is superior to industrial baby formulas (though the latter is helpful when necessary), natural conception is probably superior if one has a choice.
From a “eugenic” standpoint, the would-be eugenicists are so eager for embryo selection that they seem to have forgotten a major source of natural selection in natural conception. Gametes, both sperm and eggs, contain a semi-random half of the organism’s genes and thus differ significantly in genetic qualities, which accounts for the variability in siblings from the same parents.
The male releases millions of gametes which compete in a winner-take-all contest to fertilize the egg. Since sperm motility is negatively associated with mutational load, it strikes me that any gains from our currently primitive understanding of polygenic scores could be overwhelmed by removing the competitive aspect of male gamete selection. We also don’t know the extent to which the woman’s body might selectively release her highest quality eggs (only a tiny portion of which will be released before menopause), as opposed to the random selection of IVF egg extraction.
This does not seem to be a huge factor, as studies of IVF children have determined no significant differences other than those to be expected from parental genetic differences (users of IVF tend to be wealthier, smarter, and older). However, given the cumulative effect of tiny correlations across generations, I wouldn’t dismiss it as costless either if multi-generational elective IVF became normative. Making children the old-fashioned way, if possible, is very Lindy.
The most famous multiple birth mother, Kate Gosselin, did not use IVF. Her sextuplets resulted from medical stimulation of her ovaries to release more eggs, combined with artificial insemination. Since most IVF practitioners now limit the number of embryos transferred, large multiple births are usually the result of stimulating medicines.
Even in an ideal situation where a surrogate helps a married couple where the mother cannot carry a child to term, surrogacy presents additional questions over whether paying a woman to provide this service is ethical or exploitive, and the trauma caused to a baby in being separated from his or her birth mother, to whom he or she bonds psychologically in perceiving her voice in-utero and smell post-birth. I would imagine a person born by surrogate would prefer to exist than not exist, and would prefer to be raised by his or her genetic parents, but the trauma to the birth mother must also be considered, whose body and mind will be asked to engage in the unnatural act imaginable, abandoning a child she has carried. At minimum, it seems bizarre to combine donor gametes with surrogacy, as the child is essentially “ordered” by some primary caregiver who neither carried nor has a maternal genetic relation with the child. And of course, since natural law demands that children who cannot be cared for by their natural parents or next-of-kin be placed in homes with married, biologically male and female parents, it also demands that no one should be allowed to use surrogacy to engineer a situation to the contrary.
Interestingly, there are perhaps just as compelling reasons for men to have children at younger ages as well. Since males continuously produce gametes, as men age their spermatogenic cells begin to degrade, on average developing two random mutations per year. In fact, the accepted standard in behavioral genetics to determine if a trait is adaptive, filling an evolutionary niche, or maladaptive due to mutations is to test whether the trait is associated with paternal age. Schizophrenia, ADHD, left-wing political views, and non-procreative sexual proclivities, for example, are all weakly but significantly associated with higher paternal age at birth. Women’s eggs are amazingly created in her ovaries when she is herself a fetus, and do not significantly genetically degrade over her lifetime, so adverse genetic outcomes are generally not associated with maternal age. So while the physical viability of eggs degrades much more quickly with age, the genetic quality of men’s gametes continuously degrades after age 30 or so while remaining physically viable for up to his entire life. Since women rarely marry younger men, and age gaps in marriage tend to grow larger the later a woman marries, this further reinforces the benefits of earlier marriage and childbearing.
An obvious exception here would be ectopic pregnancies, which are a state of disease which never result in live birth and endanger the mother’s life.
As I am centering my argument on ensoulment, it’s important to distinguish between this and humanist utilitarian arguments about consciousness and self-awareness. Unconscious and non-self-aware humans have souls and are protected by natural law. For example, it is not moral to kill someone if they are anesthetized first, or like Peter Singer argues, to kill born children before they have a full sense of self. The key question is not when embryos are aware or conscious, or can feel pain, but when, as the catechism states, they “have souls that will last forever.” Ensoulment is a discrete event, perhaps unknowable, where a unique human life begins. If I had to speculate, I’d say ensoulment is a bottom-up process emerging from the developing nervous system sometime early in the first trimester.
Pietist types will insist here that the couple should adopt instead. Sure, they have that option, but not the obligation, except perhaps in next-of-kin situations, and adoption is not equivalent to natural children. Adoption of strangers is an extraordinary calling of charity for some subject to serious considerations of wisdom, not a moral obligation, whereas natural children are the normative result of the marital union. A desire for one’s natural children specifically — “be fruitful and multiply” — is healthy and virtuous, not selfish.
For example, there are women with certain uterine conditions that prevent implantation, which means if she is sexually active eggs are being fertilized, failing to implant, and dying regularly at a 100% rate. Yet, anti-IVF activists do not counsel, based on natural revelation, that such women must be celibate, even in marriage. If not, why not? Is death of an embryo ok if it happens naturally when a viable alternative exists to prevent it? If treatment of the condition and IVF gives a fertilized egg a 20% chance instead of a 0% chance to implant, why do they protest? Their distinction strikes me as arbitrary.
Morning after contraception is not chemical abortion of a developing child, but rather thins the uterine lining to prevent implantation in a manner similar to a woman’s natural cycle when embryos routinely die. Practically, any ban on morning-after contraception would be impossible to enforce, as it is simply a higher dose of easily obtainable generic medicines. Further, prosecutors would have difficulty proving beyond a reasonable doubt that the medication was taken and that an embryo was necessarily present.
Gene therapies now exist to cure Spinal Muscular Atrophy in infants, the most common genetic disease resulting often from a de novo mutation. Is this eugenics? Given the connotation of the word, it ought to only refer to coercive efforts to influence human reproduction. Under this modified definition, the largest source of eugenics today is government-sponsored welfare programs that tax and discourage productive people from having children and incentivize irresponsible reproduction. While right-wingers might call this dysgenic, from the Left’s perspective, this is good and eugenic because it increases their voting base. Ethics aside, I’m personally as skeptical of the effectiveness of central planning of reproduction as that of economic production.