Author: D. Ignacio Carrasco de Paula,Bishop of Tapso was President of the Pontifical Academy for Life
Is it morally licit to use medically assisted reproduction in a woman? The response of the Congregation – a laconic but unequivocal non-licere, it is not licit – was ultimately confirmed the unanimous opinion of the most accredited moralists. But in what measure medically assisted could be morally acceptable help fecundation process to be achieved?
I take it for granted that the opposition, in line of principle, of the Catholic Church with respect to medically assisted procreation (MAP) is sufficiently well known by the reader. The fundamental texts (I refer particularly to the instruction Donum vitae)1 are easily accessible and furthermore, the latest edition of the Catechism of the Catholic Church 2 states, with the clarity and concision typical of this literary genre, some of the ethical limits of these biotechnologies.
Therefore, my objective is not to explain that doctrine, but rather to examine some terminological, conceptual and hermeneutic issues that are essential for the correct interpretation and application of Church doctrine.
In the last fifty years, Catholic philosophy and theology have come a long way in the understanding of the nature and meaning of human love, and, with it, the understanding of the father/mother- child relationship. The use of the phenomenological method, and especially the personalist approach, has provided new cognitive instruments, correcting an excessively legalistic view of the marital experience. In some rare cases it has been possible to fall into the other end of the spectrum: a personalist perspective that is too one-sided and runs the risk of marginalising the consideration of the ontological aspects that underlie love and human procreation.
It is precisely to eliminate that risk that these reflections start from the anthropological question: What is man? An appropriate answer, perhaps the most common today in the Christian cultural con- text, is the following: man is a person, understanding by person both the Boethian meaning (subsistent individual himself endowed with a rational nature) and the axiological perspective characteristic of modernity (an end in himself and never a mere instrument).
Another possible answer, no less appropriate although somewhat fallen into disuse, appeals to the Aristotelian paradigm of a rational animal (zoon logikon) in its double aspect indicative of the ontological status (what it is) and the ethical status (what it should choose to be). Since it is rationality that makes homo sapiens into a human being, it stands as the universal rule that regulates his behaviour. The contemporary statement “act according to what you are” (a person or corporeal being able to manage his own life) constitutes the core of what we call natural law.
This latter concept has almost disappeared from ethics treatises, leaving behind a huge vacuum that the category dignity is attempting to fill. It is an obvious process in bioethics. It is a proper procedure, but requires quite a few caveats, since natural law and dignity are not superimposable axiological profiles. Dignity invites us to choose according to what one is worth, the natural law according to what one is. Both concepts are certainly closely related, but they are not the same, and neither is it always possible to reach the same conclusions with them.
The complexity of the speculative context in which human pro-creation is placed cannot be covered from the single concept of dignity. A parallel moral reflection attentive to the metaphysical foundations is required, a reflection such as that crystallised in the second part of the Summa Theologica of Saint Thomas and which the anti-metaphysical bias assumed by modernity has helped to marginalise. That prejudice is perhaps the worst and most tragic mistake of modernity.
The natural moral law has very little to do with mechanical laws or legal regulations. For it, the so-called naturalist fallacy has no value (it would be wrong to move from is to ought), as the natural moral law does not access the moral plane from the physical plane mechanically or automatically. The natural moral law does not impose rigid categorical imperatives like “you must do this”, but rather proposes reasonable choices in the style of “you should choose to do this”. The natural moral law is present only where man can opt be-tween behaving or not as befits the person or human nature, so that the ethical reflection would be a futile exercise if it could not be sup- ported by an anthropological reflection. It is no accident that the loss of interest in the natural moral law coincides with the invasion of moral relativism.
Moral significance of “artificiality”. Natural vs unnatural
Since the very beginning, in referring to MAP, the Magisterium has used the adjective “artificial”: artificial insemination, artificial fertilisation. Some authors see in this an early denunciation of the ethical negativity of both procedures: reproducing with the aid of an artifice that which in itself is a natural process would necessarily entail corrupting it. However, this theory is erroneous, or at least arguable.
In 1949, at the IV congress of the IFCMA, Pius XII3 explained that the reservations held against artificial insemination and/or fertilisation by the Catholic Magisterium “does not necessarily prohibit the use of artificial means”. Why then is this adjective used, even with the risk of confusing less sensible persons? Because that is the terminology legitimately imposed by scientific language.
In general, science, and also medicine, coins terms that describe a human action or process or state, dispensing with its moral significance; e.g. the clinical expression “suspend fluids” in itself indicates nothing more than the decision to withdraw water provided intravenously or subcutaneously. In order for this act to be morally classified, as well as “what is done”, “the reason why it is done”4 (intentionality) must also be taken into account, e.g. to relieve a generalised oedematous condition, or to reduce care during the terminal phase of a disease to only the essential, or even to obtain death by dehydration. In the latter case, “suspend fluids” would no longer be a therapeutic act like the other two, but a euthanasia practice.5
Artificial insemination (AI) per se means that the semen has reached the female genital tract, not as the exclusive result of a conjugal act, but thanks to the use of an instrument, an artifice (a cannula). Whatever the moral sign of that action, positive or negative, is another matter altogether, since it does not depend on the nature of the instrument used, but on how its instrumental use (that way of inseminating) is positioned (type of causality) with respect to the natural process of the procreative function: Does it modify it? Facilitate it? Impede it? Etc.
AI can work in the procreative process in two different ways: 1. by introducing the male semen obtained outside the conjugal act into the uterus, thereby substituting or marginalising that act, or 2. by collecting the semen ejaculated in the vaginal recess and successively transferring it past uterine cervix, and in that case helping to over- come to an obstacle that causes sterility. The difference between these two modes is obvious, and crucial to the moral assessment. An artificial means is used in both cases, but in one it prevails over the natural act and replaces it, while the other, on the contrary, is placed at its service, it supports it.
There is a net difference in meaning between “natural” applied “to what is present or is given or produced by nature” (ontic level) and “natural” applied “to proper free action or in accordance with the way of being or nature of man” (ethical level). Classical philosophical language spoke of secundum naturam or also secundum rationem, since suitability or conformity is not decided automatically but is recognised by reason (recta ratio), thus making a good and free decision possible. The formulation is complicated, but it is something that we do without difficulty every day.
Once and for all: that which opposes natural in its moral meaning is not the artificial, but what is contrary to reason, the unreasonable, the irrational.
It is understood thus because disregarding the marital act to create a child is unnatural, i.e. it is not reasonable, either from the point of view of the couple who aspire to become parents, or from the point of view of the child who could be conceived. It is not reasonable for many reasons, e.g. due to some unacceptable collateral practices (gamete donation) or because that procedure violates the dignity of the persons involved, etc., but above all because it does not make sense (it would be irrational) to leave aside the only moment (the conjugal union) that gives the spouses true procreative causality. Without that union, in the best case, the spouses would only supply the biological material required, but they would not truly be parents, even though they behave as such in the education of the newly conceived being.
On the contrary, using a cannula to help to overcome an anatomical obstacle which makes a conjugal act sterile is reasonable, just as it is reasonable to resort to hormone or surgical treatment when necessary to recover fertility.
We are thus faced with a core principle: human procreation is in accordance with the way of being human, it is natural or reasonable, when it takes place through the conjugal act. This act is secundum naturam in both senses cited: it forms part of the process intended by nature and, in turn, consents to the free participation of the spouses in the creation of a child through an act of donation which is at the same time bodily and spiritual.
Human procreation, production and reproduction: the logic of benevolence
Remember that by procreation we understand that human behaviour that sets the biological conditions necessary to enable a new human being to be conceived. This term contrasts with production (manufacture or transformation of a thing) and reproduction (manufacture or generation of an identical item or a copy).
A person is neither a thing nor a simple copy representative of its species: each human individual is a unique being, inimitable and irreplaceable. Procreation follows a logic given to the person, such as the logic of benevolence (freely wanting good for another), the logic of the unconditional gift. Production and reproduction also have their logic, but it is not the logic of benevolence; it is the logic of productivity, the logic of obtaining satisfactory results for those who put it into practice (although not only for them).
The techniques used for MAP, which include in-vitro fertilisation with subsequent embryo transfer into a womb (IVF-ET), are placed in the logic of productivity, a logic that cannot not exclude a quality control mechanism to reject defective products. In fact, the evolution of IVF-ET, from its beginnings in 1978, has always pursued the best product possible according to the standards in use and the desires of the clients. Hence the simultaneous use of several embryos, the introduction of intracytoplasmic sperm injection into the ovum (ICSI), preimplantation diagnosis, embryo reduction, etc. It is very difficult for something that does not come from benevolence to be loved un- conditionally.
Both the instrumental logic of IVF-ET, with some of its secondary consequences (in particular, embryo manipulation and loss) alone support a consistently negative moral judgement. However, as Don- um vitae expressly states, not even the “simple case” (which theoretically should avoid those problems as it occurs with a single embryo) merits a different assessment.
Why? Because these techniques themselves violate the ordo naturae, from the time at which it is unreasonable for a human being to be caused, to be put into being, by virtue of a technical procedure, neither does it seem reasonable that two spouses who cannot create a child, choose to assume a passive role or a role of simple material cause in a biotechnological process which effectively sets the bio- logical conditions necessary for the conception of the child.6 In other words, in human procreation, technique logic takes the place of the logic of benevolence; in reality, the spouses do not “give” existence to that child, they only “wish” it, “request” it and, if all goes well, “receive” it. Once in their arms though, the spouses can embrace it, restoring the ties of benevolence that are essential to the father/mother-child relationship.
Ethical discernment of MAP: central role of the spousal union
The introduction of AI in obstetric practice at the end of the XIX century as a new therapeutic standard for the treatment of some forms of sterility encountered many difficulties from an ethical point of view. One of course was the understandable resistance to transferring a biotechnology developed in animal husbandry to the human world. In the Catholic sphere, several bishops asked the Congregation of the Holy Office for guidance. The question was formulated as follows: an adhiberi possit artificialis mulieris fe- cundatio? Is it morally licit to use AI in a woman? The response of the Congregation – a laconic but unequivocal non licere, it is not licit – was published in 1897 and ultimately confirmed the unani- mous opinion of the most accredited moralists of the time. In fact, the technique as it was practiced then consisted of two unaccept- able elements: 1. the sperm was obtained by masturbation, and therefore, 2. the conjugal act was dispensed with. Later, another serious problem would be added, by using sperm provided by a person other than the husband.
Fifty-two years would pass before the Magisterium of the Church would explain the reasons for this negative judgement in detail, and it would do so in an address by Pius XII in 1949,7 in order to moder- ate and channel the debate and arguments wielded among experts in favor of and against AI. Essentially, the Holy Father emphasised the following:
1. Only the spouses have a reciprocal right over their own bodies to engender new life, an exclusive and unalienable right (excluding the use of donors);
2. While it is true that AI can generate a child and that the desire of the couple to be parents is legitimate in itself (natural, reason- able), that is not sufficient to legitimise the use of that technique (it is not the same to be able to do something or want to do it, than to have the right to do it);
3. In contrast, the use of instruments “solely destined either to fa- cilitate the natural act or to cause the natural act normally accom- plished to attain its end” may be licit.
That is, the correct ethical discernment of MAP establishes that:
1. The conjugal union is the only ontologically and ethically ap- propriate foundation for the generation of a human being;
2. Simultaneously, any eventual medical treatment of sterility should be designed as an aid to, and never as a replacement for, the conjugal union.
Indeed, as we have seen, there is a substantial ontological and ethical difference between “aid” and “replace”: simple aid respects the father/mother-child relationship, while replacement irreversibly breaks that relationship, since the eventual conception of a child would be an effect caused by the medical act.8
Ethical discernment of MAP: “in vivo” conception
The Magisterium of the Church has also been concerned with an- other problem related with human procreation and apparently oppo- site in sign to infertility treatments; I am referring to contraception.
In 1930, Pius XI addressed the issue of contraception for the first time in an Encyclical (Casti Connubii),9 defining it as “any use whatsoever of matrimony exercised in such a way that the act is de- liberately frustrated in its natural power to generate life”. Almost forty years later, Paul VI, in another Encyclical, HumanaeVitae,10 explained the principle better, speaking of “the inseparable connec- tion between the two meanings of the conjugal act: the unitive sig- nificance and the procreative significance” Both expressions – “pro- creative virtue” and “inseparable connection” – are placed in the cat- egory of causality. Contraception is a behaviour that aims to strip the conjugal union of a power bestowed on it by nature, i.e. to be the source of existence of a new human being.
Oddly enough, that same action occurs in IVF-ET, although with one difference: contraception counteracts the procreative power of the conjugal union, while in IVF-ET that power is transferred to an- other situation: to the doctor who handles the test tube or who per- forms the ICSI.
Hence the correct ethical discernment of MAP assumes that the fertilisation and conception of a new human being occurs in its nat- ural (or reasonable) place, i.e. “in vivo” (in the woman’s genital tract) and never “in vitro” (in the laboratory).
This condition is required not only to respect the causality rela- tionship between conjugal union and procreation, but also to protect the newly conceived being so that he or she cannot be an object of manipulation and/or discrimination (preimplantation diagnosis, cry- opreservation, etc.).
At this point, I do not think it out of place for the reader to ask some questions such as the following:
1. Is it morally acceptable to help spouses with infertility problems to satisfy their legitimate desire to become parents?
2. Is it morally acceptable to do so, not only with pharmacological and surgical treatments, but also, when these are not adequate, with an appropriate MAP?
3. Does a MAP technique that is effective, while also licit and respectful of the ethical imperatives of the natural moral law really exist?
Such deep questions underscore the extreme complexity of the ethical issues that accompany MAP. Do not forget that we are talking about something that was considered impossible until recently: the procreation of a human being, of a new person, of someone who, as the Christian faith teaches, is called to friendship with God and to participate in the intimate life of God. It is reasonable, therefore, that the ethical criteria are extremely stringent, which does not preclude an affirmative answer to the questions above.11
In fact there are no arguments, either from a clinical or ethical point of view, to exclude a priori the possibility of an appropriate MAP, unless the possibility of distinguishing between the natural and irrational, between the licit and illicit, between the correct or incorrect application of the teachings of the Catholic Church is denied.12
I would like to conclude by recalling a widely shared truth: boys and girls conceived thanks to MAP procedures, of whom there are many today (they exceed a million), are rightfully persons, they are children of God, they exist because God has not refused to infuse them with a rational and immortal soul. These children have come to our world in a different way than would have been reasonable, but, despite this, or perhaps because of this, they are completely welcome, because from their conception until their natural death, they deserve to be treated as what they are: people called to participate in Christ of the Eternal life of God.
1 CONGREGATION FOR THE DOCTRINE OF THE FAITH. Instruction “Donum Vitae” (22 Febru- ary 1987).
2 Catechism of the Catholic Church (15 august 1997), nn. 2376-2378.
3 PIUS XII. Address at the IV International Congress of Catholic Doctors. IFCMA .
4 ANSCOMBE GEM. Modern Moral Philosophy. Philosophy 1958; 33: 1-19.
5 This is the case of Terry Schiavo and Eluana Englaro.
6 In IVF-ET, the technical act is efficient cause and not only instrumental cause of the cre- ation. It is instead an instrument of desire of the aspiring parent
7 Ibid 3
8 Some manuals use the expression “Improper Artificial Insemination” to refer to proce- dures that respect the conjugal act. I think that this terminology should be avoided: what AI is or is not is established by Medicine; what is licit or not, and why, corresponds to Ethics.
9 PIUS XI. Encyclical Letter“Casti Connubii” (31 December 1930).
10 PAUL VI. Encyclical Letter “Humanae Vitae” (25 July 1968).
11 I do not want to go into the analysis of the innumerable variants of MAP that currently exist, as this is a topic that requires separate treatment. However thirty years ago, moralists of renowned authority and prestige believed, for example, that the technique of GIFT (col- lection of gametes in the context of a conjugal act and immediate transfer separately to the Fallopian tube) met the necessary ethical conditions. Curiously, Donum vitae avoids contra- dicting this opinion.
12 Some people hold that any instrumental intervention in natural procreation violates the principle of “inseparability” between the unitive dimension and procreative dimension of the conjugal act formulated by Humanae vitae. However, that argument assumes that the conjugal act and coitus (penetration) are the same thing.