Medical technologies like in vitro fertilization (IVF) raise as many questions as they answer. Read comments by Arthur Caplan, the Emmanuel and Robert Hart Professor of Bioethics and the director of the Center for Bioethics at the University of Pennsylvania, and Robert George, the McCormick Professor of Jurisprudence and the director of the James Madison Program in American Ideals and Institutions at Princeton University.
Robert George: I think when Louise Brown was born, it really startled the public and got people thinking and talking… at least initially, [it] made a lot of people more positive toward biotechnology than they had been. After all, her birth appeared to make it the case that the problem of infertility would be solved. People were too optimistic about that. Of course in the majority of cases, in vitro fertilization does not result in a successful pregnancy. But nevertheless, a lot of people were very enthusiastic and saw this as solving a terrible problem. And infertility certainly is a terrible problem, terrible burden for people to have to bear.
Arthur Caplan: The day Louise Brown got made was the day that a core aspect of human life, reproduction, moved from a mystery to a technology, moved from something that we were in awe of to something that we manipulate. And that was really the significance. It put reproduction, if you will, under our control. If you add Louise Brown to the birth control pill, you really see a fundamental shift in human life, because what used to be something that most of our ancestors thought of as determined by God or the gods, all of a sudden got determined by a person or two people about when and how to have a kid. As profound as you’re going to get, in all of human existence. There’s nothing more contentious, morally in dispute, and the object of discussion, than sex. So learning to do things without sex, that might lead to babies, learning to make a break between procreation and reproduction, there’s nothing more basic you’re going to change before or since in the history of humanity.
Robert George: ...A legitimate concern [was and still is] that widespread in vitro fertilization, the conceiving of children outside of ordinary marital sexual union in essentially technical circumstances, would lead us to view children, at a kind of deep level, as operational objectives, as products that are for us to conceive on our own terms and in our own way…
...The long-term impact of that [would] be to have us treat disabled children or retarded children… as “laboratory mistakes,” as failures of technology. When we move to the conceiving of children as a kind of technical process, it’s natural for people subtly and gradually to come to think of the process as one to which quality controls should be applied. You’re meant to get a good product, a product that works, the product that you wanted. Well, what if you don’t get that product? What if the child is retarded? What if the child is handicapped in some physical way?
Arthur Caplan: There had been a long literature — Aldous Huxley, many other science fiction writers — who’d suggested that test tube baby technology wasn’t about infertility. It was about eugenics. It was about making super-babies, perfect babies, better babies. It also wasn’t about what infertile couples would choose to do. It was about what government and authoritarian states would force you to do if you wanted to have a child. So part of the antsyness about this technology had nothing to do with Landrum Shettles trying to make a human embryo in a dish for an infertile couple. It had to do with this imagery that was around, that somewhere Big Brother was going to decide: Why would we let just any old people decide to hook up and get married and have kids? Let’s do it scientifically. Let’s do it in a test tube. Let’s control it. And let’s try to select traits in children that would be useful for society. So the connection from the test tube baby was to the imagery of George Orwell or Aldous Huxley, to the science fiction concerns about, Are we going to breed ourselves to improve ourselves?
Robert George: There’s a health concern, about what, in the long term, physical consequences of IVF conception will be… We all breathed a sigh of relief when Louise Brown was born and was healthy, or at least appeared to be healthy. It seemed at the time as though the concerns that IVF might be risky from a health vantage point had been misplaced. But now that the cohort of children originally conceived by IVF has entered its late twenties and early thirties, the anecdotal evidence is beginning to pile up that there are long-term health consequences, negative health consequences of IVFconceptions. Now, we don’t know whether that can be rigorously demonstrated. As I say, we only have anecdotal evidence. But it’s critically important that we do the studies that will enable us to know whether in fact, over the long term, there are higher rates of disease, morbidity, among children conceived in IVF. It’s very important for the future that potential parents who are contemplating the use of in vitro fertilization know what the potential health risks, if any, are for the children whom they will conceive.
Arthur Caplan: I think the field ducked the issue [of safety] in part because they didn’t do long-term follow-up studies. They basically said, “These babies look fine.” I remember Steptoe and Edwards sort of displaying Louise Brown around and saying, “Look, all her parts are here. She’s happy. Safety, not a big deal. We’ve got a technique that’s going to work.” But that didn’t prove that there wasn’t premature death or unusual amounts of morbidity in these kids. And I don’t think the field ever really did demonstrate its safety the way it should have.
Arthur Caplan: The technology quickly fell into a corporate ethos. It became a business. It became something that was heavily marketed. It became something that was advertised, even for a time, with what I would describe as false advertising. People would say, “We’ll get you a baby,” but they wouldn’t say what their success rate was, or they wouldn’t admit that they had a lot of failures. So the critics were worried about government control, but actually it was corporate control that came to create problems for reproductive technology.
A lot of the critics had worried about this idea of unnaturalness. Well, that faded immediately. Nobody has ever come up to me and said, you know, “I’m stigmatized. I’m a test tube baby.” I mean, no one talks that way… Nobody cares about this. We don’t actually have any notion of stigma that associates with being made this way, any more than if I said, “You know, I was born with a forceps-assisted delivery.” Nobody cares. And that’s the attitude about test tube baby technology. People worried that you’d be seen as a freak or some kind of monster, just by being made that way. That never happened at all. Our culture is so friendly to technology that nobody really cared if you started off in a dish or in a bedroom or wherever you started.
Robert George: In vitro fertilization is a way of creating a new human being, in the embryonic stage, in a petri dish, outside of a human body. Embryonic stem cell research involves the destruction of the embryo in order to obtain stem cells, which might then be used for scientific purposes…
...We have an industry that has created perhaps as many as 400,000 excess embryos, human beings in the embryonic stage of development, who are now in a kind of never-never-land, a kind of limbo, frozen in cryopreservation units…
...We don’t know whether they will, in the end, as their proponents are suggesting, have therapeutic value, but they’re probably useful in basic science, and some people would find that sufficient to support even embryo destruction, to obtain stem cells for research. But there are plenty of people who favor in vitro fertilization and plenty of people who have themselves undergone in vitro treatment, who are opposed to the destruction of embryos, who are very concerned that the embryos who are created be allowed to continue their natural development. And of course there are some people who are opposed to in vitro fertilization, but who think that once in vitro fertilization takes place, and embryos are created, and some of those embryos are excess embryos that probably won’t be implanted and so will have very little in the way of a life prospect (they’ll be frozen away, for example), some people who oppose IVF nevertheless say, well, we should use those embryos, even if it means destroying them, in order to obtain their stem cells. I myself don’t take that view.
Arthur Caplan: If you look today at current debates about stem cell technology, as Yogi Berra once said, “It’s deja vu all over again.” All the debates are the same. I see a complete cycling of worries about the moral status of embryos, the safety of the procedure in terms of making cells by stem cell engineering that are not abnormal, that wouldn’t, if put in your body, kill you or run amok. There’s a lot of concern about the unnaturalness of stem cell engineering. There’s a fair amount of concern, if you will, that stem cell technology is just not a nice thing to do, that it’s yucky to do it — even if it does cure people. So many of the issues that came up around in vitro fertilization have reverberations and echoes into debates about things like stem cell research.
I think bioethics, even the early bioethics, did identify all the right questions to ask about test tube baby technologies. The politicians didn’t have the willpower to bring those issues into the policy arena, or to bring them up for public discussion. So part of the reason we’re still having fights, even today, about reproductive technologies or about stem cell research technologies, is that two decades ago politicians basically said, “Yeah, I know there are issues, but I don’t want anything to do with them.” So we are living, if you will, with the legacy of political cowardice, not so much ethical blindness…
...We’ve got 400,000 embryos and growing every day, in this country, that we don’t know what to do with, because we’ve never answered the question: Who’s got custody? Who can control them? Who determines their fate? So that’s an obvious place to regulate…
...What they did, both at the state legislatures and the federal legislature, was say, “Okay. Abortion is going to cost me votes. Whatever I do, it’s going to get people mad at me. This technology is all about embryos. Embryos get me in the middle of the abortion debate. I’m not talking about that. Goodbye. I don’t want to legislate, regulate, or have anything to say here.” So the legacy of that avoidance is that we never had a kind of sustained public debate about any of those questions, and we, in a sense, stumble toward answers but we never resolve them.
Arthur Caplan: I’ve always been fascinated about the fact that no one, to my knowledge, has ever demonstrated, picketed, chained themselves to the doorway of an in vitro fertilization clinic. And it’s not because there have not been condemnations from important religious leaders about the immorality of test tube baby technology. It’s not because critics haven’t worked themselves up to worry about where this is all going. We’ve even had a Nobel Prize sperm bank that operated in the United States for many, many years, and no one tried to do anything to stop its function.
Test tube baby technology is seen by almost every American as pro-life technology. Normally those who worry about this technology say: Is this the right way to make a baby? Is this an acceptable way to make a baby? I think most Americans say: Who cares? If you get babies, and infertile couples want them, and they’re the biological offspring of those couples, and those couples don’t have many other options (adoption being something that’s relatively difficult to do), then this is a great technology. There’s no reason at all to try and chain yourself to the door of the infertility clinic. If you did so, people would walk around you. You’d get no sympathy, you’d have no interest, because this technology is just seen as so pro-life that even if it involves embryo destruction or weird things like using a surrogate mother, there is no way you’re going to build a movement against it.
And we can see that even today. The president in 2001 said, “I’m against embryo destruction, and we’re not going to have any more stem cell research paid for by government money.” But the President of the United States has never lifted a finger to stop embryo destruction in infertility clinics. He can’t. He would become persona non grata all over the country if he stepped in and said, “I’m sorry, infertile people, you can’t destroy embryos in the process of trying to have children.” That’s not just a politically viable point of view.
Robert George: We cannot simply lay aside the debate over in vitro fertilization, because after all, in vitro fertilization has made it possible for some couples who would otherwise not have children to have children. Even knowing that it has made that possible for couples, and applauding the happiness that couples have because of the children who were born to them in that way, we still must have the debate. Questions of human dignity and questions of human health are implicated. Those questions have not been answered, and we need to answer them. That can only be done in a democratic society by civil, respectful, if intense, democratic debate.
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